Survey of management of first-ever seizures in a hospital based community

Résumé Contexte: Bon nombre d'études épidémiologiques concernant les premières crises comitiales ont été effectuées principalement sur des populations générales. Cependant, les patients admis dans un hôpital peuvent présenter des éléments cliniques différents. Nous avons donc mené une étude prospective auprès de sujets dans une population hospitalière ayant subi une première crise d'épilepsie, afin d'étudier leur pronostic et le rôle des examens complémentaires (examen neurologique, imagerie cérébrale, examens sanguins, EEG) dans le choix de l'administration d'une médication antiépileptique. Méthodes : Sur une période d'une année, nous avons suivi 177 patients adultes, admis consécutivement, ayant présenté une crise d'épilepsie dont l'évaluation aiguë a été effectuée dans notre hôpital. Pendant 6 mois, nous avons pratiqué pour chaque patient un suivi du traitement antiépileptique, des récidives de crises et d'un éventuel décès. Résultats : L'examen neurologique était anormal dans 72.3% des cas, l'imagerie cérébrale dans 54.8% et les examens sanguins dans 57.1%. L'EEG a montré des éléments épileptiformes dans 33.9% des cas. L'étiologie la plus fréquemment représentée était constituée par des intoxications. Un traitement antiépileptique a été prescrit chez 51% des patients. 31.6% des sujets suivis à six mois ont subi une récidive ; la mortalité s'est élevée à 17.8%. Statistiquement, l'imagerie cérébrale, l'EEG et l'examen neurologique étaient des facteurs prédictifs indépendants pour l'administration d'antiépileptiques, et l'imagerie cérébrale le seul facteur associé au pronostic. Conclusions : Les patients évalués en aigu dans un hôpital pour une première crise comitiale présentent un profil médical sous-jacent, qui explique probablement leur mauvais pronostic. L'imagerie cérébrale s'est avérée être le test paraclinique le plus important dans la prévention du traitement et du pronostic. Mots-clés : première crise d'épilepsie, étiologie, pronostic, récidive, médication antiépileptique, population hospitalière Summary Background: Epidemiological studies focusing on first-ever seizures have been carried out mainly on community based populations. However, since hospital populations may display varying clinical features, we prospectively analysed patients with first-ever seizure in a hospital based community to evaluate prognosis and the role of complementary investigations in the decision to administer antiepileptic drugs (AED). Methods: Over one year, we recruited 177 consecutive adult patients with a first seizure acutely evaluated in our hospital. During six months' follow-up data relating to AED treatment, recurrence of seizures and death were collected for each patient. Results:. Neurological examination was abnormal in 72.3%, neuroimaging in 54.8% and biochemical tests in 57.1%. Electroencephalogram (EEG) showed epileptiform features in 33.9%. Toxicity represented the most common aetiology. AED was prescribed in 51% of patients. Seizure recurrence at six months involved 31.6% of patients completing the follow-up; mortality was 17.8%. Statistical analysis showed that brain CT, EEG and neurological examination are independent predictive factors for AED administration, but only CT scan is associated with outcome. Conclusions: Patients evaluated acutely for first- ever seizure in a hospital setting have severe underlying clinical conditions apparently related to their relatively poor prognosis. Neuroimaging represents the most important paraclinical test in predicting both treatment administration and outcome.

GIS and geodatabases application to global scale plate tectonics modelling

Les reconstructions palinspastiques fournissent le cadre idéal à de nombreuses études géologiques, géographiques, océanographique ou climatiques. En tant qu?historiens de la terre, les "reconstructeurs" essayent d?en déchiffrer le passé. Depuis qu?ils savent que les continents bougent, les géologues essayent de retracer leur évolution à travers les âges. Si l?idée originale de Wegener était révolutionnaire au début du siècle passé, nous savons depuis le début des années « soixante » que les continents ne "dérivent" pas sans but au milieu des océans mais sont inclus dans un sur-ensemble associant croûte « continentale » et « océanique »: les plaques tectoniques. Malheureusement, pour des raisons historiques aussi bien que techniques, cette idée ne reçoit toujours pas l'écho suffisant parmi la communauté des reconstructeurs. Néanmoins, nous sommes intimement convaincus qu?en appliquant certaines méthodes et certains principes il est possible d?échapper à l?approche "Wégenerienne" traditionnelle pour enfin tendre vers la tectonique des plaques. Le but principal du présent travail est d?exposer, avec tous les détails nécessaires, nos outils et méthodes. Partant des données paléomagnétiques et paléogéographiques classiquement utilisées pour les reconstructions, nous avons développé une nouvelle méthodologie replaçant les plaques tectoniques et leur cinématique au coeur du problème. En utilisant des assemblages continentaux (aussi appelés "assemblées clés") comme des points d?ancrage répartis sur toute la durée de notre étude (allant de l?Eocène jusqu?au Cambrien), nous développons des scénarios géodynamiques permettant de passer de l?une à l?autre en allant du passé vers le présent. Entre deux étapes, les plaques lithosphériques sont peu à peu reconstruites en additionnant/ supprimant les matériels océaniques (symbolisés par des isochrones synthétiques) aux continents. Excepté lors des collisions, les plaques sont bougées comme des entités propres et rigides. A travers les âges, les seuls éléments évoluant sont les limites de plaques. Elles sont préservées aux cours du temps et suivent une évolution géodynamique consistante tout en formant toujours un réseau interconnecté à travers l?espace. Cette approche appelée "limites de plaques dynamiques" intègre de multiples facteurs parmi lesquels la flottabilité des plaques, les taux d'accrétions aux rides, les courbes de subsidence, les données stratigraphiques et paléobiogéographiques aussi bien que les évènements tectoniques et magmatiques majeurs. Cette méthode offre ainsi un bon contrôle sur la cinématique des plaques et fournit de sévères contraintes au modèle. Cette approche "multi-source" nécessite une organisation et une gestion des données efficaces. Avant le début de cette étude, les masses de données nécessaires était devenues un obstacle difficilement surmontable. Les SIG (Systèmes d?Information Géographiques) et les géo-databases sont des outils informatiques spécialement dédiés à la gestion, au stockage et à l?analyse des données spatialement référencées et de leurs attributs. Grâce au développement dans ArcGIS de la base de données PaleoDyn nous avons pu convertir cette masse de données discontinues en informations géodynamiques précieuses et facilement accessibles pour la création des reconstructions. Dans le même temps, grâce à des outils spécialement développés, nous avons, tout à la fois, facilité le travail de reconstruction (tâches automatisées) et amélioré le modèle en développant fortement le contrôle cinématique par la création de modèles de vitesses des plaques. Sur la base des 340 terranes nouvellement définis, nous avons ainsi développé un set de 35 reconstructions auxquelles est toujours associé un modèle de vitesse. Grâce à cet ensemble de données unique, nous pouvons maintenant aborder des problématiques majeurs de la géologie moderne telles que l?étude des variations du niveau marin et des changements climatiques. Nous avons commencé par aborder un autre problème majeur (et non définitivement élucidé!) de la tectonique moderne: les mécanismes contrôlant les mouvements des plaques. Nous avons pu observer que, tout au long de l?histoire de la terre, les pôles de rotation des plaques (décrivant les mouvements des plaques à la surface de la terre) tendent à se répartir le long d'une bande allant du Pacifique Nord au Nord de l'Amérique du Sud, l'Atlantique Central, l'Afrique du Nord, l'Asie Centrale jusqu'au Japon. Fondamentalement, cette répartition signifie que les plaques ont tendance à fuir ce plan médian. En l'absence d'un biais méthodologique que nous n'aurions pas identifié, nous avons interprété ce phénomène comme reflétant l'influence séculaire de la Lune sur le mouvement des plaques. La Lune sur le mouvement des plaques. Le domaine océanique est la clé de voute de notre modèle. Nous avons attaché un intérêt tout particulier à le reconstruire avec beaucoup de détails. Dans ce modèle, la croûte océanique est préservée d?une reconstruction à l?autre. Le matériel crustal y est symbolisé sous la forme d?isochrones synthétiques dont nous connaissons les âges. Nous avons également reconstruit les marges (actives ou passives), les rides médio-océaniques et les subductions intra-océaniques. En utilisant ce set de données très détaillé, nous avons pu développer des modèles bathymétriques 3-D unique offrant une précision bien supérieure aux précédents.<br/><br/>Palinspastic reconstructions offer an ideal framework for geological, geographical, oceanographic and climatology studies. As historians of the Earth, "reconstructers" try to decipher the past. Since they know that continents are moving, geologists a trying to retrieve the continents distributions through ages. If Wegener?s view of continent motions was revolutionary at the beginning of the 20th century, we know, since the Early 1960?s that continents are not drifting without goal in the oceanic realm but are included in a larger set including, all at once, the oceanic and the continental crust: the tectonic plates. Unfortunately, mainly due to technical and historical issues, this idea seems not to receive a sufficient echo among our particularly concerned community. However, we are intimately convinced that, by applying specific methods and principles we can escape the traditional "Wegenerian" point of view to, at last, reach real plate tectonics. This is the main aim of this study to defend this point of view by exposing, with all necessary details, our methods and tools. Starting with the paleomagnetic and paleogeographic data classically used in reconstruction studies, we developed a modern methodology placing the plates and their kinematics at the centre of the issue. Using assemblies of continents (referred as "key assemblies") as anchors distributed all along the scope of our study (ranging from Eocene time to Cambrian time) we develop geodynamic scenarios leading from one to the next, from the past to the present. In between, lithospheric plates are progressively reconstructed by adding/removing oceanic material (symbolized by synthetic isochrones) to major continents. Except during collisions, plates are moved as single rigid entities. The only evolving elements are the plate boundaries which are preserved and follow a consistent geodynamical evolution through time and form an interconnected network through space. This "dynamic plate boundaries" approach integrates plate buoyancy factors, oceans spreading rates, subsidence patterns, stratigraphic and paleobiogeographic data, as well as major tectonic and magmatic events. It offers a good control on plate kinematics and provides severe constraints for the model. This multi-sources approach requires an efficient data management. Prior to this study, the critical mass of necessary data became a sorely surmountable obstacle. GIS and geodatabases are modern informatics tools of specifically devoted to store, analyze and manage data and associated attributes spatially referenced on the Earth. By developing the PaleoDyn database in ArcGIS software we converted the mass of scattered data offered by the geological records into valuable geodynamical information easily accessible for reconstructions creation. In the same time, by programming specific tools we, all at once, facilitated the reconstruction work (tasks automation) and enhanced the model (by highly increasing the kinematic control of plate motions thanks to plate velocity models). Based on the 340 terranes properly defined, we developed a revised set of 35 reconstructions associated to their own velocity models. Using this unique dataset we are now able to tackle major issues of the geology (such as the global sea-level variations and climate changes). We started by studying one of the major unsolved issues of the modern plate tectonics: the driving mechanism of plate motions. We observed that, all along the Earth?s history, plates rotation poles (describing plate motions across the Earth?s surface) tend to follow a slight linear distribution along a band going from the Northern Pacific through Northern South-America, Central Atlantic, Northern Africa, Central Asia up to Japan. Basically, it sighifies that plates tend to escape this median plan. In the absence of a non-identified methodological bias, we interpreted it as the potential secular influence ot the Moon on plate motions. The oceanic realms are the cornerstone of our model and we attached a particular interest to reconstruct them with many details. In this model, the oceanic crust is preserved from one reconstruction to the next. The crustal material is symbolised by the synthetic isochrons from which we know the ages. We also reconstruct the margins (active or passive), ridges and intra-oceanic subductions. Using this detailed oceanic dataset, we developed unique 3-D bathymetric models offering a better precision than all the previously existing ones.

Low C-reactive protein values at admission predict mortality in patients with severe community-acquired pneumonia caused by Streptococcus pneumoniae that require intensive care management.

PURPOSE: To identify risk factors associated with mortality in patients with severe community-acquired pneumonia (CAP) caused by S. pneumoniae who require intensive care unit (ICU) management, and to assess the prognostic values of these risk factors at the time of admission. METHODS: Retrospective analysis of all consecutive patients with CAP caused by S. pneumoniae who were admitted to the 32-bed medico-surgical ICU of a community and referral university hospital between 2002 and 2011. Univariate and multivariate analyses were performed on variables available at admission. RESULTS: Among the 77 adult patients with severe CAP caused by S. pneumoniae who required ICU management, 12 patients died (observed mortality rate 15.6 %). Univariate analysis indicated that septic shock and low C-reactive protein (CRP) values at admission were associated with an increased risk of death. In a multivariate model, after adjustment for age and gender, septic shock [odds ratio (OR), confidence interval 95 %; 4.96, 1.11-22.25; p = 0.036], and CRP (OR 0.99, 0.98-0.99 p = 0.034) remained significantly associated with death. Finally, we assessed the discriminative ability of CRP to predict mortality by computing its receiver operating characteristic curve. The CRP value cut-off for the best sensitivity and specificity was 169.5 mg/L to predict hospital mortality with an area under the curve of 0.72 (0.55-0.89). CONCLUSIONS: The mortality of patients with S. pneumoniae CAP requiring ICU management was much lower than predicted by severity scores. The presence of septic shock and a CRP value at admission <169.5 mg/L predicted a fatal outcome.

The role of community and population ecology in applying mycorrhizal fungi for improved food security.

The global human population is expected to reach ∼9 billion by 2050. Feeding this many people represents a major challenge requiring global crop yield increases of up to 100%. Microbial symbionts of plants such as arbuscular mycorrhizal fungi (AMF) represent a huge, but unrealized resource for improving yields of globally important crops, especially in the tropics. We argue that the application of AMF in agriculture is too simplistic and ignores basic ecological principals. To achieve this challenge, a community and population ecology approach can contribute greatly. First, ecologists could significantly improve our understanding of the determinants of the survival of introduced AMF, the role of adaptability and intraspecific diversity of AMF and whether inoculation has a direct or indirect effect on plant production. Second, we call for extensive metagenomics as well as population genomics studies that are crucial to assess the environmental impact that introduction of non-local AMF may have on native AMF communities and populations. Finally, we plead for an ecologically sound use of AMF in efforts to increase food security at a global scale in a sustainable manner.

Using a blog to create and support a Community of Inquiry in Secondary Education

Understanding how blogs can support collaborative learning is a vital concern for researchers and teachers. This paper explores how blogs may be used to support Secondary Education students’ collaborative interaction and how such an interaction process can promote the creation of a Community of Inquiry to enhance critical thinking and meaningful learning. We designed, implemented and evaluated a science case-based project in which fifteen secondary students participated. Students worked in the science blogging project during 4 months. We asked students to be collaboratively engaged in purposeful critical discourse and reflection in their blogs in order to solve collectively science challenges and construct meaning about topics related to Astronomy and Space Sciences. Through student comments posted in the blog, our findings showed that the blog environment afforded the construction of a Community of Inquiry and therefore the creation of an effective online collaborative learning community. In student blog comments, the three presences for collaborative learning took place: cognitive, social, and teaching presence. Moreover, our research found a positive correlation among the three presences –cognitive, social and teaching– of the Community of Inquiry model with the level of learning obtained by the students. We discuss a series of issues that instructors should consider when blogs are incorporated into teaching and learning. We claim that embedded scaffolds to help students to argue and reason their comments in the blog are required to foster blog-supported collaborative learning.

The prevalence of child sexual abuse in community and student samples: A meta-analysis

Background: Studies conducted internationally confirm that child sexual abuse is a much more widespread problem than previously thought, with even the lowest prevalence rates including a large number of victims that need to be taken into account. Objective: To carry out a meta-analysis of the prevalence of child sexual abuse in order to establish an overall international figure. Methods: Studies were retrieved from various electronic databases. The measure of interest was the prevalence of abuse reported in each article, these values being combined via a random effects model. A detailed analysis was conducted of the effects of various moderator variables. Results: Sixty-five articles covering 22 countries were included. The analysis showed that 7.9% of men (7.4% without outliers) and 19.7% of women (19.2% without outliers) had suffered some form of sexual abuse prior to the age of eighteen. Conclusions: The results of the present meta-analysis indicate that child sexual abuse is a serious problem in the countries analysed.

Assessment of the water chemistry and the macroinvertebrate community changes produced during the creation of the new Llobregat river mouth (Barcelona, NE Spain)

In 1999, a set of coordinated projects and investments whose principal objective was to transform Barcelona into one of the main distribution points of southern Europe resulted in the relocation of the Llobregat River mouth. The mouth was relocated by draining the old river mouth and constructing a new one. The aim of this study was to characterise the physico-chemical properties and the aquatic macroinvertebrate communities of the new river mouth and to monitor the changes experienced by the estuarine environment during its creation. A sampling point was established in the river 1.8 km upstream from its connection with the new mouth, and two sampling points were established in the new mouth. Samples of water and macroinvertebrates were collected every two months from May 2004 to June 2005, covering the periods before (from May to September 2004) and after (from September 2004 to June 2005) the new mouth was connected to the river and the sea. During the period before its connection to the river and the sea, the new mouth was functionally similar to a lagoon, with clear waters, charophytes and a rich invertebrate community. After the connection was completed, seawater penetrated the river mouth and extended to the connection point with the river (approximately 3.9 km upstream). An increase in conductivity from 4-6 mS cm 1 to 24-30 mS cm 1 caused important changes in the macroinvertebrate community of the new mouth. An initial defaunation was followed by a colonisation of the new mouth by brackish-water and marine invertebrate species. Due to its design (which allows the penetration of the sea) and the decreased discharge from the lower part of the Llobregat River, the new mouth has become an arm of the sea

Implementing evidence-based patient and family education on oral anticoagulation therapy: a community-based participatory project.

AIMS AND OBJECTIVES: This study aimed at developing and implementing evidence-based patient and family education on oral anticoagulation therapy. BACKGROUND: The number of persons with chronic diseases who live at home is increasing. They have to manage multiple diseases and complex treatments. One such treatment is oral anticoagulation therapy, a high risk variable dose medication. Adherence to oral anticoagulation therapy is jeopardised by limited information about the medications, their risk and complications, the impact of individual daily routine and the limited inclusion of family members in education. Hence, improved and tailored education is essential for patients and families to manage oral anticoagulation therapy at home. DESIGN AND METHODS: A community-based participatory research design combined with the Precede-Proceed model was used including a systematic literature review, posteducation analysis, an online nurse survey, a documentation analysis and patient/family interviews. The study was conducted between April 2010-December 2012 at a department of general internal medicine in a teaching hospital in Switzerland. Participants were the department's nursing and medical professionals including the patients and their families. RESULTS: The evidence-based patient and family education on oral anticoagulation therapy emerged comprising a learning assessment, teaching units, clarification of responsibilities of nurse professionals and documentation guidelines. CONCLUSION AND CLINICAL RELEVANCE: The inclusion of the whole department has contributed to the development and implementation of this evidence-based patient family education on oral anticoagulation therapy, which encompasses local characteristics and patient preferences. This education is now being used throughout the department.

Effect of corticosteroids on the clinical course of community-acquired pneumonia: a randomized controlled trial

Introduction The benefit of corticosteroids as adjunctive treatment in patients with severe community-acquired pneumonia (CAP) requiring hospital admission remains unclear. This study aimed to evaluate the impact of corticosteroid treatment on outcomes in patients with CAP. Methods This was a prospective, double-blind and randomized study. All patients received treatment with ceftriaxone plus levofloxacin and methyl-prednisolone (MPDN) administered randomly and blindly as an initial bolus, followed by a tapering regimen, or placebo. Results Of the 56 patients included in the study, 28 (50%) were treated with concomitant corticosteroids. Patients included in the MPDN group show a more favourable evolution of the pO2/FiO2 ratio and faster decrease of fever, as well as greater radiological improvement at seven days. The time to resolution of morbidity was also significantly shorter in this group. Six patients met the criteria for mechanical ventilation (MV): five in the placebo group (22.7%) and one in the MPDN group (4.3%). The duration of MV was 13 days (interquartile range 7 to 26 days) for the placebo group and three days for the only case in the MPDN group. The differences did not reach statistical significance. Interleukin (IL)-6 and C-reactive protein (CRP) showed a significantly quicker decrease after 24 h of treatment among patients treated with MPDN. No differences in mortality were found among groups. Conclusions MPDN treatment, in combination with antibiotics, improves respiratory failure and accelerates the timing of clinical resolution of severe CAP needing hospital admission.

Posttraumatic stress avoidance symptoms as mediators in the development of alcohol use disorders after exposure to childhood sexual abuse in a Swiss community sample.

This study examined the role of posttraumatic stress disorder (PTSD) symptoms of re-experience, avoidance, and hyperarousal in the relationship between different types of trauma and alcohol use disorders (AUD). We used data from 731 trauma-exposed individuals who participated in the first wave of the PsyCoLaus-study. Trauma characteristics were assessed relatively to the occurrence of lifetime PTSD symptoms and AUD. The results suggest that lifetime and childhood sexual abuse as well as overall childhood trauma were directly linked to AUD and PTSD symptoms, in particular to avoidance symptoms. From single symptom clusters PTSD avoidance was found to specifically mediate the trauma-AUD pathway. Both childhood and sexual trauma strongly contribute to the comorbidity of PTSD and AUD and avoidance-type symptoms appear to play a central role in maintaining this association. Hence, the alleviation of avoidance symptoms might be an important target for therapeutic intervention among victims of sexual abuse before specific addiction treatment is initiated.

Cost-effectiveness of a community pharmacist intervention in patients with depression: a randomized controlled trial (PRODEFAR study)

Background: Non-adherence to antidepressants generates higher costs for the treatment of depression. Little is known about the cost-effectiveness of pharmacist's interventions aimed at improving adherence to antidepressants. The study aimed to evaluate the cost-effectiveness of a community pharmacist intervention in comparison with usual care in depressed patients initiating treatment with antidepressants in primary care. Methods: Patients were recruited by general practitioners and randomized to community pharmacist intervention (87) that received an educational intervention and usual care (92). Adherence to antidepressants, clinical symptoms, Quality-Adjusted Life-Years (QALYs), use of healthcare services and productivity losses were measured at baseline, 3 and 6 months. Results: There were no significant differences between groups in costs or effects. From a societal perspective, the incremental cost-effectiveness ratio (ICER) for the community pharmacist intervention compared with usual care was 1,866 for extra adherent patient and 9,872 per extra QALY. In terms of remission of depressive symptoms, the usual care dominated the community pharmacist intervention. If willingness to pay (WTP) is 30,000 per extra adherent patient, remission of symptoms or QALYs, the probability of the community pharmacist intervention being cost-effective was 0.71, 0.46 and 0.75, respectively (societal perspective). From a healthcare perspective, the probability of the community pharmacist intervention being cost-effective in terms of adherence, QALYs and remission was of 0.71, 0.76 and 0.46, respectively, if WTP is 30,000. Conclusion: A brief community pharmacist intervention addressed to depressed patients initiating antidepressant treatment showed a probability of being cost-effective of 0.71 and 0.75 in terms of improvement of adherence and QALYs, respectively, when compared to usual care. Regular implementation of the community pharmacist intervention is not recommended.

Impacts of Globalization Processes on the Swiss National Business Elite Community : A Diachronic Analysis of Swiss Large Corporations (1980-2010)

This paper investigates the impacts of globalization processes on the Swiss business elite community during the 1980-2010 period. Switzerland has been characterized in the 20th century by its extraordinary stability and by the strong cohesion of its elite community. To study recent changes, we focus on Switzerland's 110 largest firms' by adopting a diachronic perspective based on three elite cohorts (1980, 2000, and 2010). An analysis of interlocking directorates allows us to describe the decline of the Swiss corporate network. The second analysis focuses on top managers' profiles in terms of education, nationality as well as participation in national community networks that used to reinforce the cultural cohesion of the Swiss elite community, especially the militia army. Our results highlight a slow but profound transformation of top management profiles, characterized by a decline of traditional national elements of legitimacy and the emergence of new "global" elements. The diachronic and combined analysis brings into light the strong cultural changes experienced by the national business elite community.