[High-throughput sequencing for infectious disease diagnoses: Example of shotgun metagenomics in central nervous system infections]

The advent of high-throughput sequencing in clinical microbiology is opening the way to new diagnostic and prognostic approaches in infectious diseases. Detection, identification and characterisation of pathogenic microorganisms are essential steps in diagnosis and implementation of appropriate antimicrobial therapy. However, standard methods of microbiological diagnosis are failing in some cases. In addition, the emergence of new infections, facilitated by international travel and global warming, requires the implementation of innovative diagnostic methods. Among the different strategies used in clinical microbiology and reviewed in this article, shotgun metagenomics is the only technique that allows today a panpathogenic and unbiased detection of all microorganisms potentially responsible for an infectious disease, including those still unknown. The aims of this article are to present the different possible strategies of high-throughput sequencing used in the microbiological diagnosis of infectious diseases and to highlight the diagnostic contribution of shotgun metagenomics in the field of central nervous system infections.

Targeting lung macrophages for fungal and parasitic pulmonary infections with innovative amphotericin B dry powder inhalers

The incidence of fungal pulmonary infections is known to be on the increase, and yet there is an alarming gap in terms of marketed antifungal therapies that are available for pulmonary administration. Amphotericin B (AmB) is a highly efficient broad-spectrum antifungal only marketed as an intravenous formulation. Based on the lack of effective antifungal and antiparasitic pulmonary treatments, the aim of this study was to develop a carbohydrate-based AmB dry powder inhaler (DPI) formulation, prepared by spray drying. Amorphous AmB microparticles were developed by combining 39.7 % AmB with 39.7 % γ-cyclodextrin, 8.1 % mannose and 12.5 % leucine. An increase in the mannose concentration from 8.1 to 29.8 %, led to partial drug crystallisation. Both formulations showed good in vitro lung deposition characteristics (80 % FPF < 5 µm and MMAD < 3 µm) at different air flow rates (60 and 30 L/min) when used with a DPI, but also during nebulisation upon reconstitution in water.

[Drug-induced acute angle closure glaucoma]

Acute angle closure glaucoma is an ophthalmic emergency that can lead to blindness in some cases. The presenting signs are often suggestive, like ocular pain and blurred vision accompanied by headache, nausea and vomiting. These symptoms must be recognized as soon as possible, and the patient must be addressed, urgently, to an ophthalmologist for treatment. Many drugs may lead to an acute angle closure glaucoma in patients with risk factors. This article aims to remind the anatomical risk factors as well as the drugs that may induce an acute angle closure glaucoma. For a better understanding, this article will provide a brief reminder of the pathophysiological mechanism of acute angle closure glaucoma.

Severity of parechovirus infections in infants under 3 months of age and comparison with enterovirus infections: A French retrospective study

While enteroviruses (EV) are a well-recognized cause of aseptic meningitis in children, human parechoviruses (HPeV), especially genotype 3, have been increasingly reported as a frequent cause of sepsis-like illness and meningitis among young infants. The aim of this study was to describe the epidemiological, clinical, and laboratory characteristics of HPeV infections in infants and to compare them with those of well-known EV infections. This monocentric retrospective study was carried out at the pediatric unit of Nantes University Hospital from January 2015 to August 2018. All patients under 18 years of age with diagnosis codes referring to fever, for whom viral infection was suspected and cerebrospinal fluid (CSF) specimens were collected, were included. All CSF specimens were screened by duplex real-time polymerase chain reaction (PCR) assay that allows for the simultaneous detection of EV and HPeV in clinical samples. During the study period, 1373 CSF specimens from patients under 18 were included. A total of 312 CSF samples were positive for HPeV (n=34) or EV (n=278). Among the 34 HPeV-positive patients, 97% (33/34) were under 3 months of age, whereas the rate was 54% (149/278) for EV-positive patients (P<0.001); thus, patients under 3 months of age were defined as the study population for the rest of this work. A review of the medical records was carried out for the positive cases. In this population, the HPeV detection rate was 5.6% versus 25.3% (P<0.001) for EV. All but one of the HPeV samples available for genotyping were HPeV-3. No seasonality was observed for HPeV infections. Length of hospital stay tended to be longer for children infected with HPeV compared with those infected by EV (3 days vs. 2 days, P=0.05). Clinicians reported more severe illness presentations among HPeV-infected infants, with more frequent administration of fluid bolus (P<0.02). Regarding laboratory characteristics, a significant lack of cellular reaction in the CSF (P=0.004) as well as lower C-reactive protein (CRP) levels (P=0.006) and neutrophil counts (P<0.001) were noted for HPeV infections compared with EV infections. Our results confirm the early onset of HPeV infections (more than 95% of patients aged under 3 months). The clinical presentation and laboratory characteristics of the two infections was similar. However, some higher clinical severity criteria and a lack of CSF pleocytosis were regularly observed in patients with HPeV infections. Considering the significant proportion (5.6%; 95% CI, 3.7-7.5) of all CSF samples in our series, HPeV detection should be systematically included in the microbiological diagnosis of febrile children under 3 months of age.

Compared presentation, management and long-term outcomes after acute myocardial infraction in men and women &lt;50 years of age. The FAST-MI programme

 

The number of young women suffering acute myocardial infarction (AMI) is increasing. There are conflicting results on the prognostic impact of gender in young patients with AMI. The aim of the present study was to assess in-hospital and 5-year outcomes in men and women ≤50 years old admitted for AMI and participating in the FAST-MI programme.

Methods

FAST-MI consists in one-month nationwide French surveys of patients admitted for a recent AMI, repeated every 5 years since 2005. We used the 2005, 2010 and 2015 data with up to 5-year follow-up, to describe baseline characteristics and outcomes according to gender in young patients. Of 13,130 patients included, 1,912 were ≤50 years old (335 women, 17.5%).

Results

Men and women had a similar age (44±5 years), BMI, current smoking (72% vs 75%), diabetes, family history, prior history of CVD, GRACE score (104±22 vs 106±23), and LVEF (54±10%). LDL at admission was lower in women (127±46 vs 138±46 mg/dl). Women had a higher admission heart rate (81±19 vs 78±17 BPM) and lower systolic blood pressure (133±26 vs 136±25 mm Hg). Presenting AMI was STEMI in 63% in women vs 68% in men (P=0.08).

All in-hospital complications except reinfarction (1.8 vs 0.6%, p&lt;0.03) were similar in women and men; in-hospital death was 1.5% vs 0.8%, P=0.20. Coronary angiography was performed slightly less often (97.6% vs 99.0%, P=0.047) and more women had non-significant coronary artery disease (CAD) (13% vs 6%, P&lt;0.001); PCI was less often used (74% vs 85.5%, P&lt;0.001). At discharge, ESC guidelines-recommended medical treatment was less often prescribed in women (41% vs 53%, P&lt;0.001), even in patients with significant CAD (46% vs 55%, P=0.004).

Kaplan-Meier 5-year survival did not differ in women (94.7%) and men (95.2%), P=0.56 (Figure). The respective figures for hospital survivors were 96.1% and 96.0% (HR 1.00, 95% CI 0.52–1.91; HR adjusted on age, type of MI, previous history of CAD, presence of significant CAD, LVEF, Killip class and appropriate medications at discharge: 0.99, 95% CI 0.51–0.92). Similar results were found for the combined end-point of death, AMI or stroke.

Conclusion

There were more similarities than differences between women and men who sustained an AMI at age ≤50 years. Women had lower LDL-c, lower haemoglobin, higher heart rate and lower blood pressure on admission. Non-significant CAD was more frequently found in women, who were less often treated with PCI and recommended medications at discharge. Five-year outcomes, however, did not differ according to gender.

Five-year mortality

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Pfizer, MSD, AstraZeneca

Augmentation des cinétiques de diffusion des composés de la pellicule des raisins rouge et blanc par des champs électriques pulsés

In recent years, Pulsed Electric Field (PEF) technology has been developing in laboratories and is starting to be established in the industry, mainly in the agri-food sector. So far all experimentations on the use of PEF in the wine industry was carried out at the laboratory scale on some kilograms of grapes, or liters of wines. Since 2015, we are studying the interest of the use of PEF on grape polyphenols extraction on a semi-industrial scale of 2 tons per hour. The first tests were carried out by comparing the PEF technology to a control, and a conventional thermovinification with liquid phase vinification and traditional vinification with different fermentation times. The first results obtained are encouraging. Vinified in the liquid phase, the grapes treated with PEF give wines with a color intensity of 20 to 30% higher than the control and a higher TPI of 7 to 17%. In the liquid phase, the treatment of the harvest by PEF does not make it possible to obtain the extraction level of the thermovinification. After a short maceration of 3 days, the polyphenols extraction level is similar to the thermovinification, and greater after 14 days, and so is the color (respectively +12 and +16%). No change in IBMP content was observed. The wines resulting from treatment of the harvest by PEF do not have the aromatic profile of thermovinification wines. The PEF has a fruity character comparable to the control and accentuates the aromatic characteristics of the grape variety. The wine are often judged less aggressive and astringent by reinforcing the perception of sweetness and full bodied. A few tests in white grape harvest by PEF, shows a significant gain of the thiols and terpenols.

The role of infection models and PK/PD modelling for optimising care of critically ill patients with severe infections

Critically ill patients with severe infections are at high risk of suboptimal antimicrobial dosing. The pharmacokinetics (PK) and pharmacodynamics (PD) of antimicrobials in these patients differ significantly from the patient groups from whose data the conventional dosing regimens were developed. Use of such regimens often results in inadequate antimicrobial concentrations at the site of infection and is associated with poor patient outcomes. In this article, we describe the potential of in vitro and in vivo infection models, clinical pharmacokinetic data and pharmacokinetic/pharmacodynamic models to guide the design of more effective antimicrobial dosing regimens. Individualised dosing, based on population PK models and patient factors (e.g. renal function and weight) known to influence antimicrobial PK, increases the probability of achieving therapeutic drug exposures while at the same time avoiding toxic concentrations. When therapeutic drug monitoring (TDM) is applied, early dose adaptation to the needs of the individual patient is possible. TDM is likely to be of particular importance for infected critically ill patients, where profound PK changes are present and prompt appropriate antibiotic therapy is crucial. In the light of the continued high mortality rates in critically ill patients with severe infections, a paradigm shift to refined dosing strategies for antimicrobials is warranted to enhance the probability of achieving drug concentrations that increase the likelihood of clinical success.

[Post-licensure safety surveillance for Prevenar 13® in France]

Objectif

Décrire le profil et l’incidence des effets indésirables (EI) notifiés avec Prévenar 13^® depuis sa commercialisation.

Méthode

Analyse de tous les effets indésirables notifiés en France entre le 1^er juillet 2010 et le 31 octobre 2014.

Résultats

En 4 ans et 4 mois, 376 déclarations d’EI dont 252 graves (67 %) ont été enregistrées, parmi lesquels 83 étaient survenus au décours d’une injection de Prévenar 13^® seul. Il s’agissait de 39 EI cutanés et 16 neurologiques, de 4 malaises, de 9 fièvres et d’une thrombopénie. L’évolution a été favorable pour 88 % des EI graves et aucun des 12 décès rapportés n’a été attribué à un EI de la vaccination. Cinquante-neuf cas d’infection pneumococcique faisant suspecter une inefficacité vaccinale ont été rapportés, mais seuls 16 ont pu être considérés comme un réel échec de la vaccination.

Discussion

Dans de nombreux cas, le Prévenar 13^® avait été administré le même jour qu’un vaccin hexavalent avec lequel l’EI rapporté était attendu. Le profil des EI rapportés au décours de l’injection de Prévenar 13^® seul est similaire à celui observé avec le Prévenar 7^®.

Conclusion

Le suivi de pharmacovigilance de Prévenar 13^® mis en place en France depuis sa commercialisation en 2010 et qui porte à ce jour sur plus de 11 800 000 doses distribuées n’a pas mis en évidence de fait nouveau de sécurité.

Relationship between adaptation and cardiovascular response to tonic cold and heat pain Adaptability to tonic pain and cardiovascular responses

BACKGROUND

The mechanisms of adaptation to tonic pain are not elucidated. We hypothesized that the adaptability to tonic pain is related to the cardiovascular system.

METHODS

Twenty-six subjects received over two sessions in a random order: tonic cold (7 ± 0.2 °C) and heat pain (47.5 ± 0.5 °C) on the hand for 5 min. Pain intensity, blood pressure (BP), and heart rate (HR) were continuously monitored.

RESULTS

Pain experience during the heat (HIT) and cold (CIT) immersion tests exhibited different average time courses, being approximated with a linear and cubic function, respectively. In each test, two groups of participants could be identified based on the time course of their tonic thermal pain: one-third of participants were pain adaptive and two-thirds non adaptive. The adaptive group exhibited higher initial pain, lower last pain, and shorter latency to peak pain than the non-adaptive one. Interestingly, some participants were adaptive to both pain stimuli, most were not. HIT as well as CIT produced a stable elevation of BP. However, BP was higher during CIT than HIT (p = 0.034). HR was also increased during CIT and HIT, but the two tests differed with respect to the time course of responses. Finally, the intensity and time course of pain rating to both HIT and CIT correlated with neither BP nor HR responses.

CONCLUSIONS

These results suggest that individual sensitivity and adaptability to tonic thermal pain is related to the intensity of initial pain rating and the latency to peak pain but not to cardiovascular responses.

[Prophylaxis of mother-to-infant transmission of hepatitis B virus]

Hepatitis B virus (HBV) infection is a worldwide health problem and mother-to-infant (or vertical) transmission is the main source of chronic infection in Asian countries. Administration of HBV vaccine to the infant at birth, with or without concurrent specific immunoglobulin, efficiently prevents such transmission (efficacy>90%). In France, testing Ag HBs is mandatory during pregnancy in all pregnant women. Infants born to Ag HBs-positive mothers should receive the first injection of vaccine and one injection of specific immunoglobulins at birth. Vaccination should thereafter be completed according to a three-injection protocol (at 1 and 6 months) or a four-injection protocol in case of prematurity. Failure of immunoprophylaxis can be observed when the viral load is very high in the mother during pregnancy (HBV-DNA levels>200,000 IU/mL). In such women, antiviral therapy with analogs (lamivudine, telbivudine, or tenofovir) during the third trimester of pregnancy and 1 month post-partum, in association with accurate immunoprophylaxis, may prevent vertical transmission. The optimal cut-off value of maternal viral load for antiviral therapy in late pregnancy and post-partum to prevent vertical transmission is still under debate.

[Catch-up vaccination of worldwide newcoming (adopted, refugee or migrant) children in France]

In France, international adoption includes around to 90,000 children since 1980 and near 300,000 immigrant children were counted in 2008. This population is heterogeneous, according to age and country of origin, and its large number. It is not easy to completely and surely assess the vaccine status of the child. Due to a great variability of individual situations, it is not possible to have systematic and unchangeable rules. This article aims to give an update of catch-up vaccination of internationally adopted or refugee or migrant children in France. The vaccination status of a child who recently arrived in France is complex and has to be adapted to his country of origin. Some of them were never vaccinated whereas the vaccine status of others is uncertain or unknown. Three parameters have to be considered: the age of the child, the country of origin, and sometimes serology in the case of doubts of his vaccine status. Catch-up vaccination of foreign children has to be adapted to French vaccine recommendations, as a reference, and to vaccines already administered to the child.

Transcutaneous electrical nerve stimulation and conditioned pain modulation influence the perception of pain in humans

BACKGROUND

Research in animal models suggests that transcutaneous electrical nerve stimulation (TENS) and conditioned pain modulation (CPM) produce analgesia via two different supraspinal pathways. No known studies have examined whether TENS and CPM applied simultaneously in human subjects will enhance the analgesic effect of either treatment alone. The purpose of the current study was to investigate whether the simultaneous application of TENS and CPM will enhance the analgesic effect of that produced by either treatment alone.

METHODS

Sixty healthy adults were randomly allocated into two groups: (1) CPM plus active TENS; (2) CPM plus placebo TENS. Pain threshold for heat (HPT) and pressure (PPT) were recorded from subject's left forearm at baseline, during CPM, during active or placebo TENS, and during CPM plus active or placebo TENS. CPM was induced by placing the subjects' contralateral arm in a hot water bath (46.5 °C) for 2 min. TENS (100 μs, 100 Hz) was applied to the forearm for 20 min at a strong but comfortable intensity.

RESULTS

Active TENS alone increased PPT (but not HPT) more than placebo TENS alone (p = 0.011). Combining CPM and active TENS did not significantly increase PPT (p = 0.232) or HPT (p = 0.423) beyond CPM plus placebo TENS. There was a significant positive association between PPT during CPM and during active TENS (r(2)  = 0.46; p = 0.003).

CONCLUSIONS

TENS application increases PPT; however, combining CPM and TENS does not increase the CPM's hypoalgesic response. CPM effect on PPT is associated with the effects of TENS on PPT.

[Current events in vaccination]

The annual meeting of the Infectious Disease Society of America (IDSA) ; which brought together nearly 5000 participants from over 80 countries in Vancouver, Canada, October 21 to 24, 2010 ; provided a review of the influenza (H1N1) 2009 pandemic, evaluated vaccination programmes and presented new vaccines under development. With 12,500 deaths in the United States in 2009-2010, the influenza (H1N1) 2009 pandemic was actually less deadly than the seasonal flu. But it essentially hit the young, and the toll calculated in years of life lost is high. The monovalent vaccines, whether live attenuated or inactivated with or without adjuvants, were well tolerated in toddlers, children, adults and pregnant women. In order to protect infants against pertussis, family members are urged to get their booster shots. The introduction of the 13-valent Pneumococcal conjugated vaccine in the beginning of 2010 may solve - but for how long ? - the problem of serotype replacement, responsible for the re-increasing incidence of invasive Pneumococcal infections observed in countries that had introduced the 7-valent vaccine. The efficacy of a rotavirus vaccine has been confirmed, with a reduction in hospitalization in the United States and a reduction in gastroenteritis-related deaths in Mexico. In the United States, vaccination of pre-adolescents against human papillomavirus (HPV) has not resulted in any specific undesirable effects. Routine vaccination against chicken pox, recommended since 1995, has not had an impact on the evolution of the incidence of shingles. Vaccination against shingles, recommended in the United States for subjects 60 years and over, shows an effectiveness of 55 %, according to a cohort study (Kaiser Permanente, Southern California). Although some propose the development of personalized vaccines according to individual genetic characteristics, the priority remains with increasing vaccine coverage, not only in infants but also in adults and the elderly. Vaccine calendars that cover a whole lifetime should be promoted, since the vaccination of adults and seniors is a determining factor of good health at all ages.

The Modified – Modified Schober Test for range of motion assessment of lumbar flexion in patients with low back pain: A study of criterion validity, intra- and inter-rater reliability and minimum metrically detectable change

PURPOSE

The objective was to estimate the psychometric properties of the Modified-Modified Schober Test (MMST).

DESIGN

This study compared range of motion measurements of lumbar flexion in low back pain (LBP) patients using the MMST with measurements calculated on X-rays as the gold standard, and compared the measurements taken by two independent examiners.

METHOD

This study was conducted at the main hospital in the Outaouais area, Quebéc, Canada. Thirty-one subjects with LBP from private and public clinics participated in the study. After a warm-up session, measurements with the MMST were taken in neutral position and an X-ray technician took an exposure in the same position.

RESULTS

Pearson's correlation test (r) between measurements made with the MMST and the gold standard, intra-class correlation coefficient (ICC), minimum metrically detectable change (MMDC) and confidence interval (CI) were used to analyze the data. The MMST demonstrated moderate validity (r=0.67; 95%CI 0.44-0.84), excellent reliability (intra: ICC=0.95; 95%CI 0.89-0.97; inter: ICC=0.91; 95%CI 0.83-0.96) and a MMDC of 1 cm.

CONCLUSIONS

In our sample of LBP patients, the MMST showed moderate validity but excellent reliability and MMDC.

[Evaluation of thymopoiesis: clinical applications]

In the precedent article, we have described how T-cell generation in the thymus (thymopoiesis) may be currently evaluated through quantification by PCR of T-cell receptor excision circles (TREC) generated by intrathymic random recombination of the gene segments coding for variable parts of T-cell receptor for antigen (TCR). In hematology, TREC methodology helps in a better understanding of immune reconstitution after graft of hematopoietic stem cells: first there is a proliferation of mature T cells present in the graft, then a differentiation of naive T cells. In geriatrics, the homeostasis of the peripheral T-cell repertoire is maintained through proliferation of peripheral memory T cells rather than through thymic generation of naive T cells. In addition, TREC quantification constitutes a novel major tool for deciphering the tight control of thymopoiesis by the neuroendocrine system.

[Clinical evaluation of thymic function]

The essential role of the thymus is to install an extremely diverse repertoire of T lymphocytes that are self-tolerant and competent against non-self, as well as to generate self-antigen specific regulatory T cells (Treg) able to inactivate in periphery self-reactive T cells having escaped the thymic censorship. Although indirect, techniques of medical imaging and phenotyping of peripheral T cells may help in the investigation of thymic function. Nowadays however, thymopoiesis is better evaluated through quantification by PCR of T-cell receptor excision circles (TREC) generated by intrathymic random recombination of the gene segments coding for the variable parts of the T-cell receptor for antigen (TCR). The TREC methodology is very valuable in the circumstances not associated with intense proliferation or apoptosis of peripheral T lymphocytes.

Pharmacokinetics of meropenem determined by microdialysis in the peritoneal fluid of patients with severe peritonitis associated with septic shock

Our objective was to describe the pharmacokinetics of meropenem in the peritoneal fluid (PF) of six patients with severe peritonitis and septic shock and to relate measured concentrations to the minimum inhibitory concentration of bacteria. Microdialysis catheters were placed into the peritoneal space during surgery. Meropenem concentrations in plasma and in PF were analyzed using compartmental modeling. Meropenem areas under the concentration-time curve were lower in PF than in plasma (average ratio, 73.8+/-15%) because of degradation confirmed ex vivo. Compartment modeling with elimination from a peripheral compartment described the data adequately, and was used to simulate steady-state concentration profiles in plasma and PF during various dosing regimens. At the currently recommended dosing regimen of 1 g infused over 20 min every 8 h, PF concentrations of meropenem in patients with severe peritonitis associated with septic shock reach values sufficient for antibacterial effects against susceptible, but not always against intermediately susceptible, bacteria.

Sex differences in opioid-mediated pain inhibitory mechanisms during the interphase in the formalin test

Many chronic pain conditions are more prevalent in women than men and both fundamental and clinical research supports the implication of endogenous pain inhibitory mechanisms. The goal of this study was to verify if sex differences on endogenous pain inhibitory mechanisms during the formalin test are opioidergic and modulated by sex hormones. Formalin tests were performed with naloxone hydrochloride, a non-selective opioid antagonist in intact and gonadectomized Sprague-Dawley rats of both sexes. Considering the sexual dimorphisms we found, where naloxone preferentially blocked the interphase in female rats, injections of all the possible combinations of mu- (naltrexone hydrochloride), delta- (naltrindole hydrochloride) and kappa-selective antagonists (norbinaltorphimine dihydrochloride) were given to evaluate the contribution of these opioid-receptor subtypes to the inhibitory mechanism during the interphase in intact females. Finally, the systemic administration of naloxone methiodide and intrathecal administration of naloxone hydrochloride in intact females allowed us to verify if the action of endogenous opioids that are liberated during the interphase takes place at the periphery or spinally, respectively. The results show that the interphase was almost completely inhibited by naloxone in females while it produced only a slight blockade in males. These results permitted us to conclude that opioids play a major role in the pain inhibitory mechanism of the interphase in females while a non-opioid mechanism seems to be responsible for this inhibitory pathway in males. Using gonadectomized animals of both sexes, we demonstrated the modulation of the opioidergic system of the interphase by sex hormones. The administration of different combinations of selective antagonists for mu-, kappa- and delta-opioid receptors in intact females permitted us to conclude that only the combination of kappa- and delta-selective antagonists significantly blocked the interphase. The same result was obtained with the combination of the three antagonists, confirming the results with systemic naloxone hydrochloride. Finally, intrathecal administration permitted us to support that the action of naloxone is primarily at the spinal level, even if a supraspinal action cannot be ruled out. These results are of particular interest in showing sexual dimorphisms in endogenous pain modulation mechanisms during the interphase of the formalin test. A clearer understanding of the difference between male and female endogenous pain inhibitory pathways should lead to a better understanding of the role of endogenous pain modulation deficits in certain chronic pain conditions.

Feelings of warmth correlate with neural activity in right anterior insular cortex

The neural coding of perception can differ from that for the physical attributes of a stimulus. Recent studies suggest that activity in right anterior insular cortex may underlie thermal perception, particularly that of cold. We now examine whether this region is also important for the perception of warmth. We applied cutaneous warm stimuli on the left leg (warmth) in normal subjects (n = 7) during functional magnetic resonance imaging (fMRI). After each stimulus, subjects rated their subjective intensity of the stimulus using a visual analogue scale (VAS), and correlations were determined between the fMRI signal and the VAS ratings. We found that intensity ratings of warmth correlated with the fMRI signal in the right (contralateral to stimulation) anterior insular cortex. These results, in conjunction with previous reports, suggest that the right anterior insular cortex is important for different types of thermal perception.

Spread of Stenotrophomonas maltophilia colonization in a pediatric intensive care unit detected by monitoring tracheal bacterial carriage and molecular typing

In our pediatric intensive care unit in Tours (France), intubated and ventilated inpatients are systematically monitored for tracheal bacterial colonization twice a week. This led us to detect five patients colonized with Stenotrophomonas maltophilia over a 4-month period. Molecular typing of the isolates using random amplified polymorphism DNA (RAPD) and pulsed-field gel electrophoresis (PFGE) confirmed that four of the five isolates were genetically related. The strict isolation of carriers and improvements in hygiene measures stopped the spread. This systematic strategy prevented pulmonary nosocomial infections or allowed their early detection. Moreover, it has made it possible to assess the efficiency of care practices continuously.

Flow control versus antisiphon valves: late results concerning slit ventricles and slit-ventricle syndrome

INTRODUCTION

The aims of the study were firstly to investigate the time course of development of slit ventricles (SV) and slit-ventricle syndrome (SVsyndrome) in hydrocephalic patients shunted as infants and secondly to assess the difference in incidence of SV and SVsyndrome in 2 groups of patients - group A with a conventional valve and group B with an anti-siphon valve.

PATIENTS AND METHODS

27 infant patients with hydrocephalus received a ventriculoperitoneal shunt and were followed prospectively with annual clinic visits and at least two CT or MRI scans postoperatively. The scans were assessed for SV, and ventricular and parenchymal surface and cortical mantle thickness were measured. Revisions for shunt malfunction were recorded.

RESULTS

SV were more frequent than SVsyndrome and developed within 6.5 months postoperatively in 21 % of patients and 48 % after 6 years. No significant difference in incidence of SV or in the surface and cortical mantle thickness were found between the two groups. Two patients (40 %) with early development of SV developed SVsyndrome, and the relative risk for shunt revision was significantly higher in patients who developed SV early. 48 % of patients did not need emergency shunt revision during the first 9 years.

CONCLUSIONS

SV develop over years. The majority of patients with SV remain asymptomatic. No significant difference between the two groups was found concerning SV and SVsyndrome. If SV develop early in the postoperative period, complications are more frequent in the long-term, so elective valve adjustment should be considered.

Transcutaneous electrical nerve stimulation (TENS) for the treatment of rheumatoid arthritis in the hand

BACKGROUND

Rheumatoid arthritis (RA) is a chronic, inflammatory, system disease. It commonly affects the small peripheral joints (such as fingers and wrist). The main goals of intervention for RA are preventing joint deformity, preserving joint function, and reducing inflammation and pain. Transelectrical nerve stimulation (TENS) is a form of electrotherapy and is thought to produce analgesia according to the gate control theory.

OBJECTIVES

To determine the efficacy and safety of TENS in the treatment of RA of the hand. The primary outcomes of interest were relief of grip pain and resting pain intensity, relief of joint tenderness, number of tender joints and patient assessment of disease. The secondary objective was to determine the most effective mode of TENS application in pain control.

SEARCH STRATEGY

We searched for relevant studies, in English, in the Cochrane field of physical and related therapies, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, HEALTHSTAR, Sports Discus, CINAHL, Current Contents, and the PEDro database, up to October 2002.

SELECTION CRITERIA

Two independent reviewers selected the trials that met predetermined inclusion criteria.

DATA COLLECTION AND ANALYSIS

Study results were extracted by two independent reviewers. Continuous outcomes were analyzed by weighted mean difference (WMD) using a fixed effects model.

MAIN RESULTS

Three RCTs, involving 78 people, were included in this review. AL-TENS and C-TENS were compared to placebo and to each other. Administration of 15 minutes of AL-TENS a week, for 3 weeks, resulted in a significant decrease in rest pain (67% relative benefit, 45 points absolute benefit on 100 mm VAS scale) but not in grip pain compared to placebo. AL-TENS did result in a clinical beneficial improvement in muscle power scores with a relative difference of 55%, and an absolute benefit of 0.98, compared to placebo. No significant difference was found between one 20-minute treatment duration of C-TENS versus AL-TENS, or C-TENS versus placebo on decrease in mean scores for rest pain or grip pain, or on the number of tender joints. Results showed a statistically significant reduction in joint tenderness, but no clinical benefit from C-TENS over placebo in relief of joint tenderness. No statistically significant difference was shown between 15 days of treatment with C-TENS or AL-TENS in relief of joint pain, although there was a clinically important benefit of C-TENS over AL-TENS on patient assessment of change in disease (risk difference 21%, NNT 5).

REVIEWER'S CONCLUSIONS

There are conflicting effects of TENS on pain outcomes in patients with RA. AL-TENS is beneficial for reducing pain intensity and improving muscle power scores over placebo while, conversely, C-TENS resulted in no clinical benefit on pain intensity compared with placebo. However C-TENS resulted in a clinical benefit on patient assessment of change in disease over AL-TENS. More well designed studies with a standardized protocol and adequate number of subjects are needed to fully conclude the effect of C-TENS and AL-TENS in the treatment of RA of the hand.

Thermotherapy for treatment of osteoarthritis

BACKGROUND

Osteoarthritis is a degenerative joint disease that affects mostly the weight-bearing joints in the knees and hips. As the affected joint degenerates pain and restriction of movement often occur. Inflammation can also occur sometimes resulting in edema of the joint with OA. Treatment focuses on decreasing pain and improving movement.

OBJECTIVES

To determine the effectiveness of thermotherapy in the treatment of OA of the knee. The outcomes of interest were relief of pain, reduction of edema, and improvement of flexion or range of motion (ROM) and function.

SEARCH STRATEGY

Two independent reviewers selected randomized and controlled clinical trials with participants with clinical and/or radiological confirmation of OA of the knee; and interventions using heat or cold therapy compared with standard treatment and/or placebo. Trials comparing head to head therapies, such as two different types of diathermy, were excluded.

SELECTION CRITERIA

Randomized and controlled clinical trials including participants with clinical or radiographical confirmation of OA of the knee; and interventions using heat or cold compared to standard treatment or placebo were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Study results were extracted by two independent reviewers. Outcomes were continuous in nature (pain, strength, improvement) and were analyzed by weighted mean difference using a fixed effects model. Graphical data were used when table data were not available.

MAIN RESULTS

Three randomized controlled trials, involving 179 patients, were included in this review. The included trials varied in terms of design, outcomes measured, cryotherapy or thermotherapy treatments and overall methodological quality. In one trial, administration of 20 minutes of ice massage, 5 days per week, for 3 weeks, compared to control demonstrated a clinically important benefit for knee OA on increasing quadriceps strength (29% relative difference). There was also a statistically significant improvement, but no clinical benefit in improving knee flexion ROM (8% relative difference) and functional status (11% relative difference). Another trial showed that cold packs decreased knee edema.

REVIEWER'S CONCLUSIONS

Ice massage compared to control had a statistically beneficial effect on ROM, function and knee strength. Cold packs decreased swelling. Hot packs had no beneficial effect on edema compared with placebo or cold application. Ice packs did not effect pain significantly compared to control in patients with OA. More well designed studies with a standardized protocol and adequate number of subjects are needed to evaluate the effect of thermotherapy in the treatment of OA of the knee.

Convulsant and subconvulsant doses of norfloxacin in the presence and absence of biphenylacetic acid alter extracellular hippocampal glutamate but not gamma-aminobutyric acid levels in conscious rats

Fluoroquinolones are antibiotics with central excitatory side effects. These adverse effects presumably result from inhibition of gamma-aminobutyric acid (GABA) binding to GABA(A) receptors. This GABA antagonistic effect is greatly potentiated by the active metabolite of fenbufen, biphenylacetic acid (BPAA). Nevertheless, it remains questionable whether GABA receptor antagonism alone can explain the convulsant activity potentials of these antimicrobial agents. The present study was undertaken to investigate the possible effects of norfloxacin, both in the absence and in the presence of BPAA, on the extracellular hippocampal levels of GABA and glutamate, the main central inhibitory and excitatory amino acid neurotransmitters, respectively. This in vivo microdialysis approach with conscious rats allows monitoring of behavioral alterations and concomitant transmitter modulation in the hippocampus. Peroral administration of 100 mg of BPAA per kg of body weight had no effect on behavior and did not significantly alter extracellular GABA or glutamate concentrations. Intravenous perfusion of 300 mg of norfloxacin per kg did not change the rat's behavior or the concomitant neurotransmitter levels in about half of the experiments, while the remaining animals exhibited severe seizures. These norfloxacin-induced convulsions did not affect extracellular hippocampal GABA levels but were accompanied by enhanced glutamate concentrations. Half of the rats receiving both 100 mg of BPAA per kg and 50 mg of norfloxacin per kg displayed lethal seizures, while the remaining animals showed no seizure-related behavior. In the latter subgroup, again no significant alterations in extracellular GABA levels were observed, but glutamate overflow remained significantly elevated for at least 3 h. In conclusion, norfloxacin exerts convulsant activity in rats, accompanied by elevations of extracellular hippocampal glutamate levels but not GABA levels, even in the presence of BPAA.

A pharmacokinetic/pharmacodynamic approach to show that not all fluoroquinolones exhibit similar sensitivity toward the proconvulsant effect of biphenyl acetic acid in rats

The proconvulsant effect of biphenyl acetic acid (BPAA) on several fluoroquinolones (FQs) was investigated in vivo, by measuring drug concentrations in the biophase at the onset of convulsions. Male Sprague-Dawley rats (n = 134) were given BPAA orally, at various doses 1 h before starting FQ infusion, which was maintained until the onset of maximal seizures, when cerebrospinal fluid (CSF) and plasma samples were collected for drug concentration determination. The FQ-BPAA interactions in the biophase (CSF) were adequately described on most occasions by an inhibitory Emax effect model with a baseline effect parameter. The efficacy of the proconvulsant effect was characterized by the ratio of the CSF concentrations of FQs at the onset of convulsant activity when BPAA was absent (CCSF0, FQs) and as BPAA CSF concentrations tended toward infinity (CCSFbase, FQs). This ratio varied from 15 for enoxacin to 1.9 for sparfloxacin. The potency of the proconvulsant effect was characterized by the CSF concentration of BPAA corresponding to a proconvulsant effect half of its maximum. This parameter varied between 0.18 +/- 0.06 micromol/L with enoxacin and 15.0 +/- 12.1 micromol/L with sparfloxacin. The CSF diffusion of all FQs was apparently non-linear, as well as the plasma protein binding of BPAA, complicating interpretation of plasma data. The important variability in the proconvulsant effect of BPAA demonstrated in this study between various FQs suggests that in vitro gamma-aminobutyric acid (GABA) binding experiments conducted in the presence of BPAA are unlikely to be good predictors of FQ convulsant risk in clinical practice.

Ventricular and parenchymal surface before and after shunting--do they have prognostic value for outcome?

PATIENTS AND METHODS

26 consecutive patients with early hydrocephalus (median age at shunting 2.5 months) were followed up to the age of 3 years, prospectively. The work-up included: regular evaluation of psychomotor development and CT/MRI prior and 6 months following surgery. The latter with measurement of the area of the ventricles (degree of hydrocephalus) and the area of the hemispheres in cm(2) (area of hemispheres minus area of ventricles = parenchymal area and degree of brain mass) at the level of the slice with the largest area of the ventricles.

RESULTS

16 (62 %) had normal development (= Group A) and 10 (38 %) moderate or severe retardation (= Group B). The mean ventricular surface was 25.4 cm(2) in Group A and 31.2 cm(2) in Group B prior to surgery (p = 0.1) and 8.9 versus 14.1 cm(2) postsurgery (p = 0.2). The percentage decrease postoperatively was 59.9, versus 57.1 % (p = 0.4). The percentage of ventricular surface in relation to the hemispheres prior to surgery was 42.2 versus 51.4 % (p = 0.1) and post-surgery 12.8 versus 22.4 % (p = 0.1). The mean parenchymal surface was 34.9 cm(2) in Group A and 29.0 cm(2) in Group B prior to surgery (p = 0.3) and 60.9 versus 48.1 cm(2) post surgery (p = 0.07). Percentage increase was 87.3 % versus 77.3 % (p = 0.9). The absolute increase was 26.0 versus 19.0 cm(2) postoperatively (p = 0.2). In contrast to these mean values and their distribution with no significant differences in Group A and B there was some correlation between development and percentage of ventricular surface in relation to the hemispheres prior to surgery: more than 40 % is a critical value, because most of the later retarded children belonged to this radiological subgroup and only half of the later normal patients. After surgery, there was a distinct correlation between developmental outcome and parenchymal surface and its absolute increase in cm(2): most of those who had a normal outcome had a parenchymal surface of more than 40 cm(2) in the third trimenon and an increase of 20 cm(2) and more within six months post surgery, whereas this was the case in only 40 - 50 % of the retarded patients.

CONCLUSIONS

In most young infants with hydrocephalus there is more brain mass than the ventricular enlargement suggests. The prognostic value of quantitative evaluation of neuroimaging should not be overestimated. Nevertheless, some prognostication in this age group is possible prior to surgery by measurement of ventricular area in relation to the hemispheres and after surgery by measurement of the parenchymal area and its increase in cm(2).