Voyages astraux et hors du corps. Héautoscopie, extase et hallucinations expérientielles d'origine épileptique [Astral and out-of-body voyages. Heautoscopy, ecstasis and experimental hallucinations of epileptic origin]

We report a 38 year-old patient who had temporoparietal epilepsy and unusual ictal "out of body" experiences that remained undiagnosed for more than ten years, until her admission for a motor seizure of the left hemibody. Out of body episodes were experienced as intense and ecstatic astral journeys. EEG showed a bilateral extension of epileptiform abnormalities to the parietal regions, predominantly on the right side. We discuss the various forms of heautoscopy and their putative mechanisms. We suggest that a disturbance in representing space in independent extrapersonal and personal coordinates might be as crucial as the elusive hypothesis of a body schema disorder. Combined involvement of the parietal neocortex and temporolimbic structures might allow those experiences to gain a subjective vividness which appears to be indissociable from normal conscious experiences.

Evolution of insulin sensitivity and its variability in out-of-hospital cardiac arrest (OHCA) patients treated with hypothermia.

INTRODUCTION: Therapeutic hypothermia (TH) is often used to treat out-of-hospital cardiac arrest (OHCA) patients who also often simultaneously receive insulin for stress-induced hyperglycaemia. However, the impact of TH on systemic metabolism and insulin resistance in critical illness is unknown. This study analyses the impact of TH on metabolism, including the evolution of insulin sensitivity (SI) and its variability, in patients with coma after OHCA. METHODS: This study uses a clinically validated, model-based measure of SI. Insulin sensitivity was identified hourly using retrospective data from 200 post-cardiac arrest patients (8,522 hours) treated with TH, shortly after admission to the intensive care unit (ICU). Blood glucose and body temperature readings were taken every one to two hours. Data were divided into three periods: 1) cool (T <35°C); 2) an idle period of two hours as normothermia was re-established; and 3) warm (T >37°C). A maximum of 24 hours each for the cool and warm periods was considered. The impact of each condition on SI is analysed per cohort and per patient for both level and hour-to-hour variability, between periods and in six-hour blocks. RESULTS: Cohort and per-patient median SI levels increase consistently by 35% to 70% and 26% to 59% (P <0.001) respectively from cool to warm. Conversely, cohort and per-patient SI variability decreased by 11.1% to 33.6% (P <0.001) for the first 12 hours of treatment. However, SI variability increases between the 18th and 30th hours over the cool to warm transition, before continuing to decrease afterward. CONCLUSIONS: OCHA patients treated with TH have significantly lower and more variable SI during the cool period, compared to the later warm period. As treatment continues, SI level rises, and variability decreases consistently except for a large, significant increase during the cool to warm transition. These results demonstrate increased resistance to insulin during mild induced hypothermia. Our study might have important implications for glycaemic control during targeted temperature management.

Theory of mind tasks and executive functions: A systematic review of group studies in neurology.

A growing number of studies have been addressing the relationship between theory of mind (TOM) and executive functions (EF) in patients with acquired neurological pathology. In order to provide a global overview on the main findings, we conducted a systematic review on group studies where we aimed to (1) evaluate the patterns of impaired and preserved abilities of both TOM and EF in groups of patients with acquired neurological pathology and (2) investigate the existence of particular relations between different EF domains and TOM tasks. The search was conducted in Pubmed/Medline. A total of 24 articles met the inclusion criteria. We considered for analysis classical clinically accepted TOM tasks (first- and second-order false belief stories, the Faux Pas test, Happe's stories, the Mind in the Eyes task, and Cartoon's tasks) and EF domains (updating, shifting, inhibition, and access). The review suggests that (1) EF and TOM appear tightly associated. However, the few dissociations observed suggest they cannot be reduced to a single function; (2) no executive subprocess could be specifically associated with TOM performances; (3) the first-order false belief task and the Happe's story task seem to be less sensitive to neurological pathologies and less associated to EF. Even though the analysis of the reviewed studies demonstrates a close relationship between TOM and EF in patients with acquired neurological pathology, the nature of this relationship must be further investigated. Studies investigating ecological consequences of TOM and EF deficits, and intervention researches may bring further contributions to this question.

Proportion of out of hospital adult non traumatic cardiac arrest presenting as a convulsion

Introduction: The majority of convulsions are due to an epilepticseizure or a convulsive syncope. In some cases, this is the firstsymptom of an out of hospital cardiac arrest (OH-CA).Objective: This study was aimed to measure the proportion of adultnon traumatic OH-CA presenting as a convulsion.Methodology: We prospectively collected all incoming calls with anout-of-hospital non traumatic seizure as the chief complaint in patients>18 years during a 24-months period. Among these calls, we collectedcases identified as OH-CA by paramedics.Results: During the 24-months period, the EMS dispatch centerreceived 561 calls for an out-of-hospital non traumatic convulsion in anadult. Twelve cases were ultimately classified as CA. In this group, onebystander spontaneously reported that the patient was known forepilepsy. The incidence of OH-CA presenting as convulsions wastherefore 2.1% of all calls for convulsion. Over the same period, theEMS dispatch center received 1035 calls related to an adult nontraumatic OH-CA. Therefore the rate of OH-CA presenting as aconvulsion represented 1.2% of all adult non traumatic OH-CA.Conclusion: Only 12 cases out of the 531 calls for non traumatic adultconvulsions were confirmed OH-CA (2.1%). Nevertheless, this unusualpresentation of OH-CA must be recognized by dispatchers, even whena patient is reported by bystander as a known epileptic. Dispatchersshould keep bystanders on line or call them back before paramedics'arrival, and have them confirm the progressive return of a normalpattern of breathing and state of consciousness; if not, they shouldencourage when necessary bystander to initiate CPR. For dispatchers,a past medical history of epilepsy should not be regarded as sufficientinformation to rule-out OH-CA. It is mandatory that known epilepticpatients should be monitored in the same way as non-epileptic patients.

The longitudinal association between social functioning and theory of mind in first episode psychosis

Introduction. There is some cross-sectional evidence that theory of mind ability is associated with social functioning in those with psychosis but the direction of this relationship is unknown. This study investigates the longitudinal association between both theory of mind and psychotic symptoms and social functioning outcome in first-episode psychosis. Methods. Fifty-four people with first-episode psychosis were followed up at 6 and 12 months. Random effects regression models were used to estimate the stability of theory of mind over time and the association between baseline theory of mind and psychotic symptoms and social functioning outcome. Results. Neither baseline theory of mind ability (regression coefficients: Hinting test 1.07 95% CI 0.74, 2.88; Visual Cartoon test 2.91 95% CI 7.32, 1.51) nor baseline symptoms (regression coefficients: positive symptoms 0.04 95% CI 1.24, 1.16; selected negative symptoms 0.15 95% CI 2.63, 2.32) were associated with social functioning outcome. There was evidence that theory of mind ability was stable over time, (regression coefficients: Hinting test 5.92 95% CI 6.66, 8.92; Visual Cartoon test score 0.13 95% CI 0.17, 0.44). Conclusions. Neither baseline theory of mind ability nor psychotic symptoms are associated with social functioning outcome. Further longitudinal work is needed to understand the origin of social functioning deficits in psychosis.

Advances in the hospital management of patients following an out of hospital cardiac arrest.

The outcome for patients after an out-of-hospital cardiac arrest (OHCA) has been poor over many decades and single interventions have mostly resulted in disappointing results. More recently, some regions have observed better outcomes after redesigning their cardiac arrest pathways. Optimised resuscitation and prehospital care is absolutely key, but in-hospital care appears to be at least as important. OHCA treatment requires a multidisciplinary approach, comparable to trauma care; the development of cardiac arrest pathways and cardiac arrest centres may dramatically improve patient care and outcomes. Besides emergency medicine physicians, intensivists and neurologists, cardiologists are playing an increasingly crucial role in the post-resuscitation management, especially by optimising cardiac output and undertaking urgent coronary angiography/intervention.

Imaging of Anorectal Malformations: Finding the Way out of the Labyrinth

Purpose/Aim: To review the embryological basis of a wide spectrum of anorectal malformations (ARM), to provide anatomical schemas showing the possiblelocations of fistulas in boys and girls and to present the typical imaging findings of these complex anomalies using various imaging methods with emphasis on3T-MRI.Content Organization: 1. Embryology. 2. Imaging techniques. 3. Normal 3T-MRI pelvic anatomy. 4. Ano-rectal malformations in boys: - Classification -Anatomic schemas of location of fistulas. - Imaging studies. 5. Ano-rectal malformations in girls: - Classification - Anatomic schemas of location of fistulas. -Imaging studies. 6. Imaging of Currarino syndrome. 7. Imaging of Vacterl syndrome.Summary: ARM are a group of complex anatomical alterations characterized by an abnormal separation of genitourinary system from hindgut. The major teachingpoints of this pictorial essay are to show: - The normal anatomy of the pelvis floor and the sphincter muscle complex in 3T-MRI. - Anatomic schemas of thedifferent types of ARM in boys and girls. - Imaging findings of a wide spectrum of ARM using a multimodality approach. including colostogramm, voidingcystourethrogramm and MRI of the pelvis.

Hemispheric asymmetry and theory of mind: Is there an association?

Introduction. In autism and schizophrenia attenuated/atypical functional hemispheric asymmetry and theory of mind impairments have been reported, suggesting common underlying neuroscientific correlates. We here investigated whether impaired theory of mind performance is associated with attenuated/atypical hemispheric asymmetry. An association may explain the co-occurrence of both dysfunctions in psychiatric populations. Methods. Healthy participants (n 129) performed a left hemisphere (lateralised lexical decision task) and right hemisphere (lateralised face decision task) dominant task as well as a visual cartoon task to assess theory of mind performance. Results. Linear regression analyses revealed inconsistent associations between theory of mind performance and functional hemisphere asymmetry: enhanced theory of mind performance was only associated with (1) faster right hemisphere language processing, and (2) reduced right hemisphere dominance for face processing (men only). Conclusions. The majority of non-significant findings suggest that theory of mind and functional hemispheric asymmetry are unrelated. Instead of ''overinterpreting'' the two significant results, discrepancies in the previous literature relating to the problem of the theory of mind concept, the variety of tasks, and the lack of normative data are discussed. We also suggest how future studies could explore a possible link between hemispheric asymmetry and theory of mind.

Incidenceof out-of-hospital adult nontraumatic cardiac arrest presenting as a convulsion

Introduction: The majority of convulsions are due to an epileptic seizure or a convulsive syncope. The incidence of out-of-hospital cardiac arrest (OH-CA) presenting as a convulsion is unknown. Objective: This study aimed to measure the incidence of adult nontraumatic OH-CA presenting as a convulsion, a rate that has not been published so far, to the best of our knowledge. Methods: We prospectively collected all incoming calls with an out-of-hospital nontraumatic seizure as the chief complaint in patients >18 years old during a 24-month period. Among these calls, we collected cases identified as OH-CA by paramedics. Results: During the 24-month period, the emergency medical services (EMS) dispatch center received 561 calls for an out-of-hospital nontraumatic convulsion in an adult. Twelve cases were ultimately classified as CA. In this group, one bystander spontaneously reported that the patient was known for epilepsy. The incidence of OH-CA presenting as convulsions was therefore 2.1% of all calls for convulsion. Over the same period, the EMS dispatch center received 1,035 calls related to an adult nontraumatic OH-CA. Therefore, the rate of OH-CA presenting as a convulsion represented 1.2% of all adult nontraumatic OH-CA. Conclusion:L Only 12 cases out of the 531 calls for nontraumatic adult convulsions were confirmed OHCA (2.1%). Nevertheless, this unusual presentation of OH-CA must be recognized by dispatchers, even when a patient is reported by bystander as a known epileptic. Dispatchers should keep bystanders on the line or call them back before paramedics' arrival, and have them confirm the progressive return of a normal pat- tern of breathing and state of consciousness; if not, they should encourage the bystander to initiate CPR when necessary. An intervention should be implemented to improve the detection by dispatchers of OH-CA presenting as convulsion by the development of a specific interview and directed observation. For dispatchers, a past medical history of epilepsy should not be regarded as sufficient information to rule out OH-CA. It is mandatory that known epileptic patients should be monitored in the same way as nonepileptic patients.

Artificial muscle to wash blood out of fibrillating atrium: an alternative to lifelong anticoagulation.

The Atripump is a motorless, volume displacement pump based on artificial muscle technology that could reproduce the pump function of normal atrium. It could help prevent blood clots due to blood stagnation and eventually avoid anticoagulation therapy in atrial fibrillation (AF). An animal study has been designed to assess mechanical effects of this pump on fibrillating atrium. The Atripump is a dome shaped silicone coated nitinol actuator. A pacemaker like control unit drives the actuator. In five adult sheep, the right atrium (RA) was exposed and dome sutured onto the epicardium. Atrial fibrillation was induced using rapid epicardial pacing (600 beats/min). Ejection fraction of the RA was obtained with intracardiac ultrasound in baseline, AF and Atripump assisted AF conditions. The dome's contraction rate was 60/min with power supply of 12V, 400 mA for 200 ms and ran for 2 hours in total. Mean temperature on the RA was 39+/-1.5 degrees C. Right atrium ejection fraction was 31% in baseline conditions, 5% and 20% in AF and assisted AF, respectively. In two animals a thrombus appeared in the right appendix and washed out once the pump was turned on. The Atripump washes blood out the RA acting as an anticoagulant device. Possible clinical implications in patients with chronic AF are prevention of embolism of cardiac origin and avoidance of hemorrhagic complication due to chronic anticoagulation.

Detection of human growth hormone doping in urine: out of competition tests are necessary.

The misuse of human growth hormone (hGH) in sport is deemed to be unethical and dangerous because of various adverse effects. Thus, it has been added to the International Olympic Committee list of banned substances. Until now, the very low concentration of hGH in the urine made its measurement difficult using classical methodology. Indeed, for routine diagnosis, only plasma measurements were available. However, unlike blood samples, urine is generally provided in abundant quantities and is, at present, the only body fluid allowed to be analysed in sport doping controls. A recently developed enzyme-linked immunosorbent assay (Norditest) makes it now possible, without any extraction, to measure urinary hGH (u-hGH) in a dynamic range of 2-50 ng hGH/l. In our protocol, untreated and treated non-athlete volunteers were followed. Some of them received therapeutical doses of recombinant hGH (Norditropin) for one week either intramuscularly (three increasing doses) or subcutaneously (12 i.u. every day). The u-hGH excretion after treatment showed dramatic increases of 50-100 times the basal values and returned to almost the mean normal level after 24 h. u-hGH was also measured in samples provided by the anti-doping controls at major and minor competitions. Depending on the type of efforts made during the competition, the hGH concentration in urine was dramatically increased. Insulin-like growth factor binding proteins and beta 2-microglobulins in urine and/or in blood could be necessary for the correct investigation of any hGH doping test procedure.