Evaluation of a clinical tool for early etiology identification in status epilepticus.

OBJECTIVES: Because early etiologic identification is critical to select appropriate specific status epilepticus (SE) management, we aim to validate a clinical tool we developed that uses history and readily available investigations to guide prompt etiologic assessment. METHODS: This prospective multicenter study included all adult patients treated for SE of all but anoxic causes from four academic centers. The proposed tool is designed as a checklist covering frequent precipitating factors for SE. The study team completed the checklist at the time the patient was identified by electroencephalography (EEG) request. Only information available in the emergency department or at the time of in-hospital SE identification was used. Concordance between the etiology indicated by the tool and the determined etiology at hospital discharge was analyzed, together with interrater agreement. RESULTS: Two hundred twelve patients were included. Concordance between the etiology hypothesis generated using the tool and the finally determined etiology was 88.7% (95% confidence interval (CI) 86.4-89.8) (κ = 0.88). Interrater agreement was 83.3% (95% CI 80.4-96) (κ = 0.81). SIGNIFICANCE: This tool is valid and reliable for identification early the etiology of an SE. Physicians managing patients in SE may benefit from using it to identify promptly the underlying etiology, thus facilitating selection of the appropriate treatment.

The Macklin effect: a frequent etiology for pneumomediastinum in severe blunt chest trauma.

STUDY OBJECTIVES: To review the etiology and pathophysiology of pneumomediastinum in severe blunt trauma, with a special interest in one of its possible origins, the Macklin effect. The Macklin effect relates to a three-step pathophysiologic process: blunt traumatic alveolar ruptures, air dissection along bronchovascular sheaths, and spreading of this blunt pulmonary interstitial emphysema into the mediastinum. The clinical relevance of the Macklin effect was also evaluated. SETTING: A university hospital serving as a reference trauma center. PATIENTS: A selection of 51 patients with severe blunt trauma between 1995 and 2000. Inclusion criteria: Severe trauma or high-speed deceleration justifying chest CT; if chest CT demonstrated a pneumomediastinum, bronchoscopy and esophagoscopy were performed to rule out tracheobronchial or esophageal injury. DESIGN: Retrospective analysis of patients' clinical files, chest CT, and bronchoscopy and esophagoscopy reports. The Macklin effect was diagnosed when an air collection adjacent to a bronchus and a pulmonary vessel could be clearly identified on the chest CT. Clinical relevance of the Macklin effect was statistically evaluated regarding its repercussions on the pulmonary gas exchange function, the respective durations of intensive care and total hospital stay, and the associated injuries. RESULTS: Twenty (39%) Macklin effects and 5 tracheobronchial injuries (10%) were identified. One tracheobronchial injury occurred simultaneously with the Macklin effect. The presence of the Macklin effect affected neither the clinical profile nor the result of pulmonary gas analysis on hospital admission, but was associated with a significant (p < 0.001) lengthening of the intensive care stay. CONCLUSIONS: The Macklin effect is present in 39% of severe blunt traumatic pneumomediastinum detected by CT. Its identification does not rule out a tracheobronchial injury. The Macklin effect reflects severe trauma, since it is associated with significantly prolonged intensive care stay.

Glial and axonal body fluid biomarkers are related to infarct volume, severity, and outcome.

Body fluid biomarkers of central nervous system damage may help improve the prognostic and diagnostic accuracy in ischemic stroke. We studied 53 patients. Stroke severity and outcome was rated using the National Institutes of Health Stroke Scale and modified Rankin scale. Ferritin, S100B, and NfH were measured in cerebrospinal fluid (CSF) and serum. Infarct volume was calculated from T2W images. CSF S100B (median 1.00 ng/mL) and CSF ferritin (10.0 ng/mL) levels were elevated in patients with stroke compared with control subjects (0.62 ng/mL, P < .0001; 2.34 ng/mL, P < .0001). Serum S100B (0.09 ng/mL) was higher in patients with stroke compared with control subjects (0.01 ng/mL). CSF S100B levels were higher in patients with a cardioembolic stroke (2.88 ng/mL) than in those with small-vessel disease (0.89 ng/mL, P < .05). CSF S100B levels correlated with the National Institutes of Health Stroke Scale score on admission (R = 0.56, P < .01) and the stroke volume (R = 0.44, P = .01). CSF S100B and NfH-SMI35 levels correlated with outcome on the modified Rankin scale. CSF S100B levels were related to stroke severity and infarct volume and highest in cardioembolic stroke.

Lésions cutanées et infiltrats pulmonaires d'évolution défavorable sans cause infectieuse [Progressive cutaneous and pulmonary lesions without infectious etiology: two cases reports of sweet syndrome with pulmonary involvement].

Sweet syndrome is a non infectious febrile disease with a neutrophilic infiltrate of dermis. Extracutaneous involvement can occur. We report two cases of Sweet syndrome with cutaneous and pulmonary involvement and give a short review of the literature of pulmonary involvement in Sweet syndrome.

Disrupting the EMMPRIN (CD147)-cyclophilin A interaction reduces infarct size and preserves systolic function after myocardial ischemia and reperfusion.

Objective-Inflammation and proteolysis crucially contribute to myocardial ischemia and reperfusion injury. The extracellular matrix metalloproteinase inducer EMMPRIN (CD147) and its ligand cyclophilin A (CyPA) may be involved in both processes. The aim of the study was to characterize the role of the CD147 and CyPA interplay in myocardial ischemia/reperfusion (I/R) injury.Methods and Results-Immunohistochemistry showed enhanced expression of CD147 and CyPA in myocardial sections from human autopsies of patients who had died from acute myocardial infarction and from mice at 24 hours after I/R. At 24 hours and 7 days after I/R, the infarct size was reduced in CD147(+/-) mice vs CD147(+/+) mice (C57Bl/6), in mice (C57Bl/6) treated with monoclonal antibody anti-CD147 vs control monoclonal antibody, and in CyPA(-/-) mice vs CyPA(+/+) mice (129S6/SvEv), all of which are associated with reduced monocyte and neutrophil recruitment at 24 hours and with a preserved systolic function at 7 days. The combination of CyPA(-/-) mice with anti-CD147 treatment did not yield further protection compared with either inhibition strategy alone. In vitro, treatment with CyPA induced monocyte chemotaxis in a CD147-and phosphatidylinositol 3-kinase-dependent manner and induced monocyte rolling and adhesion to endothelium (human umbilical vein endothelial cells) under flow in a CD147-dependent manner.Conclusion-CD147 and its ligand CyPA are inflammatory mediators after myocardial ischemia and reperfusion and represent potential targets to prevent myocardial I/R injury.

Ätiologie und Management der Gicht [The etiology and management of gout].

Gout is an inflammatory arthritis caused by monosodium urate (MSU) crystal deposits in and around the joint. The formation of urinary calculi can also occur in gout, but are less common than arthritis. Gout usually presents with recurrent episodes of joint inflammation, which over time lead to tophus formation and joint destruction. In the last decade, significant advances have been made regarding not only the epidemiology and genetics of gout and hyperuricemia but also the mechanisms of inflammation and treatment of gout. In addition, knowledge concerning the key role of interleukin 1 (IL-1) has provided new therapeutic perspectives. However, the current management of gout is often suboptimal, with many Patienten either not receiving adequate treatment or being unable to tolerate existing treatments. New therapeutic agents provide interesting new options for Patienten with difficult-to-treat gouty arthritis.The English full-text version of this is available at SpringerLink (under "Supplemental").

Etiology of community-acquired pneumonia in hospitalized children based on WHO clinical guidelines.

Community-acquired pneumonia (CAP) is a major cause of death in developing countries and of morbidity in developed countries. The objective of the study was to define the causative agents among children hospitalized for CAP defined by WHO guidelines and to correlate etiology with clinical severity and surrogate markers. Investigations included an extensive etiological workup. A potential causative agent was detected in 86% of the 99 enrolled patients, with evidence of bacterial (53%), viral (67%), and mixed (33%) infections. Streptococcus pneumoniae was accounted for in 46% of CAP. Dehydration was the only clinical sign associated with bacterial pneumonia. CRP and PCT were significantly higher in bacterial infections. Increasing the number of diagnostic tests identifies potential causes of CAP in up to 86% of children, indicating a high prevalence of viruses and frequent co-infections. The high proportion of pneumococcal infections re-emphasizes the importance of pneumococcal immunization.

Pacemaker therapy in patients with neurally mediated syncope and documented asystole: Third International Study on Syncope of Uncertain Etiology (ISSUE-3): a randomized trial.

BACKGROUND: The efficacy of cardiac pacing for prevention of syncopal recurrences in patients with neurally mediated syncope is controversial. We wanted to determine whether pacing therapy reduces syncopal recurrences in patients with severe asystolic neurally mediated syncope. METHODS AND RESULTS: Double-blind, randomized placebo-controlled study conducted in 29 centers in the Third International Study on Syncope of Uncertain Etiology (ISSUE-3) trial. Patients were ≥40 years, had experienced ≥3 syncopal episodes in the previous 2 years. Initially, 511 patients, received an implantable loop recorder; 89 of these had documentation of syncope with ≥3 s asystole or ≥6 s asystole without syncope within 12 ± 10 months and met criteria for pacemaker implantation; 77 of 89 patients were randomly assigned to dual-chamber pacing with rate drop response or to sensing only. The data were analyzed on intention-to-treat principle. There was syncope recurrence during follow-up in 27 patients, 19 of whom had been assigned to pacemaker OFF and 8 to pacemaker ON. The 2-year estimated syncope recurrence rate was 57% (95% CI, 40-74) with pacemaker OFF and 25% (95% CI, 13-45) with pacemaker ON (log rank: P=0.039 at the threshold of statistical significance of 0.04). The risk of recurrence was reduced by 57% (95% CI, 4-81). Five patients had procedural complications: lead dislodgment in 4 requiring correction and subclavian vein thrombosis in 1 patient. CONCLUSIONS: Dual-chamber permanent pacing is effective in reducing recurrence of syncope in patients ≥40 years with severe asystolic neurally mediated syncope. The observed 32% absolute and 57% relative reduction in syncope recurrence support this invasive treatment for the relatively benign neurally mediated syncope. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00359203.

Mesenteric venous thrombosis: MDCT features according to the underlying etiology [C-463]

Purpose: To work out certain, well‑defined aetiologies frequently associated with mesenteric venous thrombosis (MVT) in order to predict a typical population at risk, since MVT is nowadays often incidentally detected on cross‑sectional imaging. To demonstrate the MDCT features, frequency and extent of associated bowel ischemia according to the underlying pathology. Methods and Materials: Our electronic database revealed 71 patients (25 women, mean age 55) with thrombosis of the superior and/or inferior mesenteric vein detected by MDCT between 2000 and 2008. Two radiologists jointly reviewed the corresponding MDCT features including intraluminal extension, underlying aetiology and associated bowel ischemia, if present. Results: MVT was associated with carcinoma in 31 (43.7%) patients (pancreas 21.1%, liver 9.9%, others 12.7%). Concomitant inflammation was seen in 15 (21.1%) patients (pancreatitis 11.3%, diverticulitis 4.2%, others 5.6%), whereas coagulation/hematologic disorders were found in 7 (9.9%) patients, liver cirrhosis in 6 (8.5%), mixed/miscellaneous causes in 5 (7%) and still unknown aetiologies in 5 patients (7%). MVT resulted from recent operations in 2 (2.8%) patients. MDCT features of venous bowel ischemia were present in 15 patients (21.1%). 46.5% of MVT were (sub)acute, while 53.5% chronic. The luminal extension was complete in 52.1%, subtotal (50% of lumen) in 22.5% and partial (50% of lumen) in 25.4% of patients, consisting either of blood clots (76.1%) or tumoral tissue (23.9%), the latter mainly due to pancreas adenocarcinoma (76.4%). Conclusion: MDCT features of MVT are seen with a wide range of underlying diseases. Signs of intestinal ischemia are infrequently associated, mostly occurring with coagulation/hematologic disorders (40%).

Syndrome hypothénarien du marteau: étiologie peu connue de phénomène de Raynaud secondaire [Hypothenar hammer syndrome: little-known etiology of secondary Raynaud's phenomenon]

Hypothenar hammer syndrome is an uncommonly encountered cause of Raynaud's phenomenon associated with professional or recreational activities. We report 6 consecutive cases seen in our angiology unit between 1988 and 1990. Clinical findings include a history of repeated microtraumatisms of the dominant hand, male sex, unilaterality, sudden onset, and severe Raynaud's phenomenon of the last three fingers. Investigations reveal an aneurysm or thrombosis of the distal cubital artery or of the superficial palmar branch, associated with occlusion of digital arteries. Avoidance of the aggravating conditions or resection and/or plasty of the affected vascular segment usually leads to disappearance of the symptoms.

Mesenteric venous thrombosis : MDCT features according to the underlying etiology : P1

Purpose: To work out certain, well-defined aetiologies frequently associated with mesenteric venous thrombosis (MVT) in order to predict a typical population at risk, since MVT is nowadays often incidentally detected on cross-sectional imaging. To demonstrate the MDCT features, frequency and extent of associated bowel ischemia according to the underlying pathology. Methods and materials: Our electronic database revealed 71 patients (25 women, mean age 55) with thrombosis of the superior and/or inferior mesenteric vein detected by MDCT between 2000 and 2008. Two radiologists jointly reviewed the corresponding MDCT features including intraluminal extension, underlying aetiology and associated bowel ischemia, if present. Results: MVT was associated with carcinoma in 31 (43.7%) patients (pancreas 21.1%, liver 9.9%, others 12.7%). Concomitant inflammation was seen in 15 (21.1%) patients (pancreatitis 11.3%, diverticulitis 4.2%, others 5.6%), whereas coagulation/hematologic disorders were found in 7 (9.9%) patients, liver cirrhosis in 6 (8.5%), mixed/miscellaneous causes in 5 (7%) and still unknown aetiologies in 5 patients (7%). MVT resulted from recent operations in 2 (2.8%) patients. MDCT features of venous bowel ischemia were present in 15 patients (21.1%). 46.5% of MVT were (sub) acute, while 53.5% chronic. The luminal extension was complete in 52.1%, subtotal (>50% of lumen) in 22.5% and partial (<50% of lumen) in 25.4% of patients, consisting either of blood clots (76.1%) or tumoral tissue (23.9%), the latter mainly due to pancreas adenocarcinoma (76.4%). Conclusion: MDCT features of MVT are seen with a wide range of underlying diseases. Signs of intestinal ischemia are infrequently associated, mostly occurring with coagulation/hematologic disorders (40%).

La thrombose de varicocèle : une étiologie rare de douleur testiculaire [Varicocele thrombosis: a rare etiology of testicular pain]

Acute testicular pain is frequent in urology. If torsion of the spermatic cord and orchiepididymitis are usual, varicocele thrombosis is an unusual clinical entity we reported.

Tendinopathies du sportif: étiologie, diagnostic et traitement [Tendinitis in athletes: etiology, diagnosis and treatment].

Tendinopathy is one of the most common diagnosis in sports. Knowledges about their etiology, the repair process to their diagnosis and their treatment have improved thanks to the development of imaging, especially ultra- sound. The disorder whose etiology could be mechanical or degenerative can cause long- term disability and sometimes the end of the sport carreer. The risk of reccurence is com- mon; this may lead to tendon rupture whose functional effects can be significative. The management should be early: it must respect the deadlines for tendon healing and pro- pose a gradual recovery efforts after elimina tion of the contributing factors involved.

Status epilepticus of inflammatory etiology: A cohort study.

OBJECTIVE: Inflammation-related epilepsy is increasingly recognized; however, studies on status epilepticus (SE) are very infrequent. We therefore aimed to determine the frequency of inflammatory etiologies in adult SE, and to assess related demographic features and outcomes. METHODS: This was a retrospective analysis of a prospective registry of adult patients with SE treated in our center, from January 2008 to June 2014, excluding postanoxic causes. We classified SE episodes into 3 etiologic categories: infectious, autoimmune, and noninflammatory. Demographic and clinical variables were analyzed regarding their relationship to etiologies and functional outcome. RESULTS: Among the 570 SE consecutive episodes, 33 (6%) were inflammatory (2.5% autoimmune; 3.3% infectious), without any change in frequency over the study period. Inflammatory SE episodes involved younger patients (mean age 53 vs 61 years, p = 0.015) and were more often refractory to initial antiepileptic treatment (58% vs 38%, odds ratio = 2.19, 95% confidence interval = 1.07-4.47, p = 0.041), despite similar clinical outcome. Subgroup analysis showed that, compared with infectious SE episodes, autoimmune SE involved younger adults (mean age 44 vs 60 years, p = 0.017) and was associated with lower morbidity (return to baseline conditions in 71% vs 32%, odds ratio = 5.41, 95% confidence interval = 1.19-24.52, p = 0.043) without any difference in mortality. CONCLUSIONS: Despite increasing awareness, inflammatory SE etiologies were relatively rare; their occurrence in younger individuals and higher refractoriness to treatment did not have any effect on outcome. Autoimmune SE episodes also occurred in younger patients, but tended to have better outcomes in survivors than infectious SE.