Origin of the relative afferent pupillary defect in optic tract lesions.

OBJECTIVE: To determine the percent decussation of pupil input fibers in humans and to explain the size and range of the log unit relative afferent pupillary defect (RAPD) in patients with optic tract lesions. DESIGN: Experimental study. PARTICIPANTS AND CONTROLS: Five patients with a unilateral optic tract lesion. METHODS: The pupil response from light stimulation of the nasal hemifield, temporal hemifield, and full field of each eye of 5 patients with a unilateral optic tract lesion was recorded using computerized binocular infrared pupillography. Six stimulus light intensities, separated by 0.5-log unit steps, were used; 12 stimulus repetitions were given for each stimulus condition. MAIN OUTCOME MEASURES: For each stimulus condition, the pupil response of each eye was characterized by plotting the mean pupil contraction amplitude as a function of stimulus light intensity. The percentage of decussating afferent pupillomotor input fibers was calculated from the ratio of the maximal pupil contractions elicited from each eye. The RAPD was determined pupillographically from full-field stimulation to each eye. RESULTS: In all patients, the pupil response from the functioning temporal hemifield ipsilateral to the tract lesion was greater than that from the functioning contralateral nasal hemifield. This temporal-nasal asymmetry increased with increasing stimulus intensity and was similar in hemifield and full-field stimuli, eventually saturating at maximal light intensity. The log unit RAPD did not correlate with the estimated percentage of decussating pupil fibers, which ranged from 54% to 67%. CONCLUSIONS: In patients with a unilateral optic tract lesion, the pupillary responses from full-field stimulation to each eye are the same as comparing the functioning temporal field with the functioning nasal field. The percentage of decussating fibers is reflected in the ratio of the maximal pupil contraction amplitudes resulting from stimulus input between the two eyes. The RAPD that occurs in this setting reflects the difference in light sensitivity between the intact temporal and nasal hemifields. Its magnitude does not correlate with the difference in the number of crossed and uncrossed axons, but its sidedness contralateral to the side of the optic tract lesion is consistent with the greater percentage of decussating pupillomotor input.

Dépistage du cancer de la prostate: utilité, buts et perspectives en 2010 [Prostate cancer screening: utility, goals and perspectives in 2010].

According to recent results of a sub-group of 20,000 patients from the ERSPC study, prostate cancer screening significantly increases disease specific survival for men with a life expectancy of 15 years. However presently, only 20% of prostate biopsies lead to the diagnosis of cancer. This low yield may be increased by using new tools on their way to validation, such as the blood and urinary markers p2-PSA and PCA3, so as MRI and tridimensional computerized echography. Finally, the tumours detected must be managed with subtlety, since a third of them are not overtly aggressive clinically. Hence, a significant proportion of such tumours may not need immediate curative intent treatment, and can be followed up in an active surveillance protocol.

Jejunojejunal intussusception after Roux-en-Y gastric bypass: a review.

Small bowel intussusception is a rare long-term complication after Roux-en-Y gastric bypass, the etiology of which remains unclear. Except for one series reporting on 23 patients, case reports represent the vast majority of all cases reported so far. With this complete review of the world literature, based on a total of 63 patients including 2 of our own cases, we provide an extensive overview of the subject. The origin of intussusception after gastric bypass is different from that of intussusception of other causes, in that there is usually no lead point. It is likely related to motility disorders in the divided small bowel, especially in the Roux limb. This rare condition may cause obstruction and lead to bowel necrosis if not recognized and treated promptly. Clinical presentation is not specific. Computerized tomography scan represents the diagnostic test of choice, but surgery is sometimes the only way to establish the diagnosis. Treatment may be limited to reduction if the small bowel is viable, but resection of the affected segment is recommended on the basis of this review, since it seems to result in fewer recurrences. Knowledge of this entity and a high index of suspicion are required to make the correct diagnosis and offer appropriate treatment in a timely fashion.

Doublecortin cells and neurodegenerative disease

Introduction : Doublecortin (DCX) is a microtubule associated protein expressed by migrating neural precursors. DCX is also expressed in approximately 4% of all cortical cells in adult normal primate brain. DCX expression is also enhanced locally in response to an acute insult made to the brain. This is thought to play a role in plasticity or neural repair. That being said, it would be interesting to know how the expression of DCX is modified in a more chronic insult, like in neurodegeneration such as in Parkinson's Disease (PD) and Alzheimer's Disease (AD). The aim of my study is to study the expression of DCX cells in the cortex of patients having a neurodegenerative disease, compared to control patients. Method: DCX cells quantification on 9 DCX‐stained 5 μm thick formalin fixed paraffin embedded brain sections: 3 Alzheimer's disease patients, 3 Parkinson's disease patients and 3 control patients. Each patient had several sections that we could stain with different stainings (GALLYA, TAU, DCX). By using a computerized image analysis system (Explora Nova, La Rochelle, France), cortical columns were selected on areas on the cortex with a lot of degeneration subjectively observed on GALLYA stained sections and on TAU stained sections. Then total number of cells was counted on TAU sections, where all nuclei were colored in blue. Then the DCX cells were counted on the corresponding DCX sections. These values were standardized to a reference surface area. The ratio of DCX cells over total cells was then calculated. Results : There is a difference of DCX cell expression between Alzheimer's Disease patients and control patients. The percentage of dcx cells in the cortex of an Alzheimer's patient is around 12.54% ± 2.17%, where as in the cortex of control patients, it is around 5.47% ± 0.83%. On the other hand, there is no significant difference in the ratio of DCX cells over total cells between parkinson's patients and control patients, both having around 5% of DCX cells. Discussion: There is a dramatic increase of DCX expression in AD (12.5%) compared to PD and controls (5.5%). The increase in DCX ratio in AD may have two potential causes: 1.The increased ratio is due to DCX cells being more resistant to degeneration compared to surrounding cells which are degenerating due to AD, leading to the cortical atrophy observed in AD patients. So the decrease of total cells without any change in the number of DCX cells makes the ratio bigger in AD compared to the controls. 2.The increased ratio is due to an actual increase in DCX cells. This means that there is some neural repair to compensate the degenerative process, just like the repair process observed in acute lesions to the brain. This second idea can be integrated in the broader point of view of neuroinflammation. The progression of the disease would trigger neuroinflammation and the process following the primary inflammatory response which is neural repair. So our study can show that the increase in DCX cells is an attempt to repair the degenerated neurons, in the context of neuroinflammation triggered by the physiopathological progression of the disease.

A whole body transportable indirect calorimeter for human use in the tropics.

A transportable, whole body indirect calorimeter, designed for use in the tropics, is described. The calorimeter was built to study energy expenditure of people having chronically or acutely low levels of food intake, and it will help to determine energy adaptations made by individuals with restricted food intake. The calorimeter comprises two units: a 27 m3 ventilated chamber connected to an office housing control and monitoring equipment. The system also allows the experimenter to assess the rate of energy expenditure by means of a ventilated hood or a baby respiration chamber. The incoming air flow rate is variable and is typically set at approximately 30 l/min. Carbon dioxide production (VCO2) and oxygen consumption (VO2) are continuously monitored by means of differential gas analysers via a computerized data acquisition unit. Gas production/consumption rates are measured with a delay of 80 s, the complete response to step changes in VCO2 or VO2 consumption being calculated over 15 min using the rate of change terms in the gas exchange equations. The total electrical power required for the whole system is 12 kW. The calorimeter has been functioning for nearly 4 years in a rural village of The Gambia during which ambient temperatures have ranged from 16 to 44 degrees C and dewpoints from -8 to 24 degrees C. The performance and accuracy of the calorimeter were tested using 20 per cent CO2 in N2 infusion and butane burning. Agreement between the theoretical and the measured values was found to be 99 per cent for VO2 and 100 per cent for VCO2 with a precision for both gases of +/- 10 ml/min over a 1-h period.

Preoperative upper gastrointestinal testing can help predicting long-term outcome after gastric banding for morbid obesity.

BACKGROUND: Gastric banding (GB) is one of the most popular bariatric procedures for morbid obesity. Apart from causing weight loss by alimentary restriction, it can interfere with functions of the esophagus and upper stomach. The aim of this study was to evaluate if the results of extensive preoperative upper GI testing were correlated with long-term outcome and complications after GB. METHODS: Using a prospectively maintained computerized database including all the patients undergoing bariatric operations in both our hospitals, we performed a retrospective analysis of the patients who underwent complete upper gastrointestinal (GI) testing (endoscopy, pH monitoring, and manometry) before GB. RESULTS: One hundred thirty-four patients underwent complete testing before GB. Abnormal pH monitoring (increased total reflux time, increased diurnal reflux time, increased number of reflux episodes) predicted the development of complications and especially pouch dilatation and food intolerance. The mean De Meester score was higher among patients who developed complications than in the remaining ones (25.4 vs 17.7, P=0.03). High lower esophageal sphincter pressure also predicted progressive long-term food intolerance. Endoscopic findings were not predictive of the long-term outcome. CONCLUSIONS: There is some association between the function of the upper digestive tract and long-term complications after gastric banding. Abnormal pH monitoring predicts overall long-term complications, especially food intolerance with or without reflux, and pouch dilatation, and a high lower esophageal sphincter pressure predicts long-term food intolerance. Extended upper gastrointestinal testing with endoscopy, 24-h pH monitoring, and esophageal manometry is probably worthwhile in selecting patients for gastric banding.

Prévalence des maladies infectieuses au Centre hospitalier universitaire vaudois [Prevalence of infectious diseases at the Vaud University Hospital Center].

The prevalence of infectious diseases at our hospital (Centre hospitalier universitaire vaudois, Lausanne [CHUV], 900 beds) was studied retrospectively over a two years period (1980-1981). The medical diagnosis of 30203 patients recorded in the computerized medical archives, representing 93% of the patients admitted during the period of observation, was reviewed. To assess the reliability of the computerized data, quality control was carried out through detailed analysis of all the histologically proven appendicitis recorded during 1981. 88% of the histologically proven appendicitis were registered in the computer and the diagnosis was specific in 87% of cases. An infectious disease was the primary reason for admission in 12.8% of the patients (3873) during the study period. Altogether, 20.2% of patients presented with an infection during their hospital stay. Because of the retrospective nature of the study it was not possible to determine whether these additional infections were nosocomially acquired. The organ systems most frequently infected were the respiratory tract (28.5% of all infections), the digestive tract (20.5%), the skin and osteoarticular system (16%) and the urogenital tract (11.6%). An infection was the primary reason for admission of 40.2% of the patients hospitalized in the dermatology service, of 19.7% of patients admitted in internal medicine, of 15-17% of the patients admitted in pediatrics, ENT and general surgery, and of 1-2% of the patients admitted in neurosurgery and radiotherapy. These observations highlight the continuing importance of infectious diseases in a modern hospital, in spite of high socio-economic levels, stringent hygiene and epidemiologic measures, and modern antibiotic availability.

Functional and morphological evidence for a ventricular conduction system in zebrafish and Xenopus hearts.

Zebrafish and Xenopus have become popular model organisms for studying vertebrate development of many organ systems, including the heart. However, it is not clear whether the single ventricular hearts of these species possess any equivalent of the specialized ventricular conduction system found in higher vertebrates. Isolated hearts of adult zebrafish (Danio rerio) and African toads (Xenopus laevis) were stained with voltage-sensitive dye and optically mapped in spontaneous and paced rhythms followed by histological examination focusing on myocardial continuity between the atrium and the ventricle. Spread of the excitation wave through the atria was uniform with average activation times of 20 +/- 2 and 50 +/- 2 ms for zebrafish and Xenopus toads, respectively. After a delay of 47 +/- 8 and 414 +/- 16 ms, the ventricle became activated first in the apical region. Ectopic ventricular activation was propagated significantly more slowly (total ventricular activation times: 24 +/- 3 vs. 14 +/- 2 ms in zebrafish and 74 +/- 14 vs. 35 +/- 9 ms in Xenopus). Although we did not observe any histologically defined tracts of specialized conduction cells within the ventricle, there were trabecular bands with prominent polysialic acid-neural cell adhesion molecule staining forming direct myocardial continuity between the atrioventricular canal and the apex of the ventricle; i.e., the site of the epicardial breakthrough. We thus conclude that these hearts are able to achieve the apex-to-base ventricular activation pattern observed in higher vertebrates in the apparent absence of differentiated conduction fascicles, suggesting that the ventricular trabeculae serve as a functional equivalent of the His-Purkinje system.

Holter implantable: reveal [The implantable loop recorder]

The implantable loop recorder developed by Medtronic (Reveal plus) is a small device inserted subcutaneously under local anesthesia in patients with syncope of unexplained origin. This device enables a single lead-ECG recording and has autonomy of two years. Memories are activated during episodes of bradycardia or tachycardia, either automatically or manually. Several studies have shown a high diagnostic rate reaching 50% and demonstrated its cost-effectiveness. There is also a significant reduction in syncopal episodes and a higher quality of life score in patients with syncope of unexplained origin.

Tumor localization of radiolabeled antibodies against carcinoembryonic antigen in patients with carcinoma: a critical evaluation.

Purified, [131I]-labeled goat antibodies against carcinoembryonic antigen, which have been shown to localize in human carcinoma in nude mice, were injected into 27 patients with carcinoma. Patients were scanned with a scintillation camera at various intervals. In 11 patients, radioactivity was detectable in the tumor 48 hours after injection. Computerized subtraction of blood-pool radioactivity provided clearer pictures in positive cases, but in 16 patients the scans remained doubtful or negative. To study the specificity of [131I]-antibody localization, we gave some patients simultaneous injections of [125I]-labeled normal IgG. Both isotopes were measured by means of scintillation counting in tumors and normal tissues recovered after surgery. The results demonstrated that only the anti-CEA antibodies localized in tumors. However, the total antibody-derived radioactivity in the tumor was only about 0.001 of the injected dose. We conclude that, despite the present demonstration of specificity, this method of tumor detection is not yet clinically useful.

Association of electrocardiogram abnormalities and incident heart failure events.

Unless effective preventive strategies are implemented, aging of the population will result in a significant worsening of the heart failure (HF) epidemic. Few data exist on whether baseline electrocardiographic (ECG) abnormalities can refine risk prediction for HF. METHODS: We examined a prospective cohort of 2,915 participants aged 70 to 79 years without preexisting HF, enrolled between April 1997 and June 1998 in the Health, Aging, and Body Composition (Health ABC) study. Minnesota Code was used to define major and minor ECG abnormalities at baseline and at year 4 follow-up. Using Cox models, we assessed (1) the association between ECG abnormalities and incident HF and (2) the incremental value of adding ECG to the Health ABC HF Risk Score using the net reclassification index. RESULTS: At baseline, 380 participants (13.0%) had minor, and 620 (21.3%) had major ECG abnormalities. During a median follow-up of 11.4 years, 485 participants (16.6%) developed incident HF. After adjusting for the Health ABC HF Risk Score variables, the hazard ratio (HR) was 1.27 (95% CI 0.96-1.68) for minor and 1.99 (95% CI 1.61-2.44) for major ECG abnormalities. At year 4, 263 participants developed new and 549 had persistent abnormalities; both were associated with increased subsequent HF risk (HR 1.94, 95% CI 1.38-2.72 for new and HR 2.35, 95% CI 1.82-3.02 for persistent ECG abnormalities). Baseline ECG correctly reclassified 10.5% of patients with HF events, 0.8% of those without HF events, and 1.4% of the overall population. The net reclassification index across the Health ABC HF risk categories was 0.11 (95% CI 0.03-0.19). CONCLUSIONS: Among older adults, baseline and new ECG abnormalities are independently associated with increased risk of HF. The contribution of ECG screening for targeted prevention of HF should be evaluated in clinical trials.

Significant decrease in in-hospital mortality and major adverse cardiac events in Swiss STEMI patients between 2000 and December 2007.

To evaluate the in-hospital outcome of STEMI (ST elevation myocardial infarction) patients admitted to Swiss hospitals between 2000 and December 2007, and to identify the predictors of in-hospital mortality and major cardiac events. Data from the Swiss national registry AMIS Plus (Acute Myocardial Infarction and Unstable Angina in Switzerland) were used. All patients admitted between January 2000 and December 2007 with STEMI or a new LBBB (left bundle branch block) were included in the registry. We studied 12 026 STEMI patients admitted to 68 hospitals. The mean age was 64 +/- 13 years and 73% of the patients were male. Incidence of in-hospital death was 7.6% in 2000 and 6% in 2007. Reinfarction fell from 3.7% in 2000 to 0.9% in 2007. Thrombolysis decreased from 40.2% in 2000 to 2% in 2007. Clinical predictors of mortality were: age >65 years, Killips class III or IV, diabetes, Q wave myocardial infarction (at presentation). Patients undergoing percutaneous coronary intervention (PCI) had lower mortality and reinfarction rates (3.9% versus 11.2% and 1.1% versus 3.1% respectively, p <0.001) over time, although their numbers increased from 43% in 2000 to 85% in 2007. Patients admitted to hospitals with PCI facilities had lower mortality than patients hospitalised in hospitals without it, but the demographic characteristics differ widely between the two groups. Both in-hospital mortality and reinfarction decreased significantly over the time, parallel to an increased number of PCI. PCI was also the strongest predictor of survival. In-hospital mortality and reinfarction rate have decreased significantly in Swiss STEMI patients in the last seven years, parallel to a significant increase in the number of percutaneous coronary interventions in addition to medical therapy. Outcome is not related to the site of admission but to PCI access.