Asthme aigu sévère [Severe acute asthma]

Acute severe asthma is defined by the occurrence of an acute exacerbation resistant to the initial medical treatment, complicated by life-threatening respiratory distress due to severe lung hyperinflation. The conventional therapeutic approach is based on oxygen therapy and on the combined treatment of inhaled beta2-agonists at repeated doses and systemic corticosteroids. Inhaled or systemic magnesium sulfate is also recommended. The unresponsiveness to the initial bronchodilating therapy and the development of respiratory distress requiring intubation significantly increases mortality, due to the complications induced by mechanical ventilation. In these situations, a ventilatory strategy, including controlled hypoventilation with permissive hypercapnia, aiming at preventing lung hyperinflation, is indicated. Non-invasive ventilation may be successful in certain patients and represents an effective alternative to intubation. In ventilated patients, helium-oxygen mixtures can be considered as adjunctive therapies. After having reviewed the basic pathophysiological principles, this article will focus on the current medical treatment and of the modalities of mechanical ventilation in acute severe asthma.

Detection of circulant tumor necrosis factor-alpha , soluble tumor necrosis factor p75 and interferon-gamma in Brazilian patients with dengue fever and dengue hemorrhagic fever

Pro-inflammatory cytokines are believed to play an important role in the pathogenesis of dengue infection. This study reports cytokine levels in a total of 54 patients examined in Recife, State of Pernambuco, Brazil. Five out of eight patients who had hemorrhagic manifestations presented tumor necrosis factor-alpha (TNF-alpha) levels in sera which were statistically higher than those recorded for controls. In contrast, only one out of 16 patients with mild manifestations had elevated TNF-alpha levels. The levels of interleukin-6 (IL), IL-1beta tested in 24 samples and IL-12 in 30 samples were not significantly increased. Interferon-g was present in 10 out of 30 patients with dengue. The data support the concept that the increased level of TNF-alpha is related to the severity of the disease. Soluble TNF receptor p75 was found in most patients but it is unlikely to be related to severity since it was found with an equivalent frequency and levels in 15 patients with dengue fever and another 15 with dengue hemorrhagic fever.

Does history of falling predict length of stay in post-acute geriatric rehabilitation?

Objectives:To investigate the associations between falls before hospital¦admission, falls during hospitalization, and length of stay in elderly¦people admitted to post-acute geriatric rehabilitation. Method: History¦of falling in the previous 12 months before admission was recorded¦among 249 older persons (mean age 82.3±7.4 years, 69.1% women)¦consecutively admitted to post-acute rehabilitation. Data on medical,¦functional and cognitive status were collected upon admission. Falls¦during hospitalization and length of stay were recorded at discharge.¦Results: Overall, 92 (40.4%) patients reported no fall in the 12 months¦before admission; 63(27.6%) reported 1 fall, and 73(32.0%) reported¦multiple falls. Previous falls occurrence (one or more falls) was significantly¦associated with in-stay falls (19.9% of previous fallers fell¦during the stay vs 7.6% in patients without history of falling, P=.01),¦and with a longer length of stay (22.4 ± 10.1 days vs 27.1 ± 14.3 days,¦P=.01). In multivariate robust regression controlling for gender, age,¦functional and cognitive status, history of falling remained significantly¦associated with longer rehabilitation stay (2.8 days more in single fallers,¦p=.05, and 3.3 days more in multiple fallers, p=.0.1, compared to¦non-fallers). Conclusion: History of falling in the 12 months prior to¦post acute geriatric rehabilitation is independently associated with a¦longer rehabilitation length of stay. Previous fallers have also an¦increased risk of falling during rehabilitation stay. This suggests that¦hospital fall prevention measures should particularly target these high¦riskpatients.

Anti-VP1 and anti-VP2 antibodies detected by immunofluorescence assays in patients with acute human parvovirus B19 infection

Acute human parvovirus B19 infection is followed by an antibody response to the structural proteins of the viral capsid (VP1 and VP2). We used 80 sera collected from 58 erythema infectiosum and 6 transient aplastic crisis patients to test IgM and IgG antibodies against these two proteins in an immunofluorescence assay (IFA) using Sf9 cells infected with recombinant baculovirus expressing either VP1 or VP2 antigen. Although less sensitive than IgM capture enzyme immunoassay using native antigen (MACEIA), we could detect anti-VP1 or anti-VP2 IgM antibodies by IFA in 49 patients with acute infection (76.6%). Detection of IgG anti-VP1 and anti-VP2 by IFA, however, was as sensitive as IgG detection by indirect enzyme immunoassay. By applying IgG avidity IFA to sera of the 15 IgM IFA negative patients we were able to confirm acute infection in further 12 cases by IFA. Overall, acute infection was confirmed by IFA in 61 (95.3%) of the 64 patients.

Detection of the acute phase of abdominal angiostrongyliasis with a parasite-specific IgG enzyme linked immunosorbent assay

Angiostrongylus costaricensis may cause intestinal lesions of varied severity when it accidentally infects man in Central and South America. First-stage larvae have never been detected in stools. Therefore, a parasite-specific IgG ELISA was evaluated for the determination of the acute phase of infection. The specificity and the sensitivity of the immunoassay was shown to be 76.2% and 91.1%, respectively. Eight serum samples taken from patients with histopathological diagnosis, at different time points (3 to 15 months) after surgical treatment, showed a sharp and early decline in antibody reactivity. The titration of anti-A. costaricensis antibodies has proved to be a useful method for the diagnosis of acute abdominal angiostrongyliasis.

Sperrin Lakeland Trust - Comprehensive Assessment of Acute Services at Sperrin Lakeland Trust

Sperrin Lakeland Trust - Comprehensive Assessment of Acute Services at Sperrin Lakeland Trust

Bacterial flagellin triggers cardiac innate immune responses and acute contractile dysfunction.

BACKGROUND: Myocardial contractile failure in septic shock may develop following direct interactions, within the heart itself, between molecular motifs released by pathogens and their specific receptors, notably those belonging to the toll-like receptor (TLR) family. Here, we determined the ability of bacterial flagellin, the ligand of mammalian TLR5, to trigger myocardial inflammation and contractile dysfunction. METHODOLOGY/PRINCIPAL FINDINGS: TLR5 expression was determined in H9c2 cardiac myoblasts, in primary rat cardiomyocytes, and in whole heart extracts from rodents and humans. The ability of flagellin to activate pro-inflammatory signaling pathways (NF-kappaB and MAP kinases) and the expression of inflammatory cytokines was investigated in H9c2 cells, and, in part, in primary cardiomyocytes, as well as in the mouse myocardium in vivo. The influence of flagellin on left ventricular function was evaluated in mice by a conductance pressure-volume catheter. Cardiomyocytes and intact myocardium disclosed significant TLR5 expression. In vitro, flagellin activated NF-kappaB, MAP kinases, and the transcription of inflammatory genes. In vivo, flagellin induced cardiac activation of NF-kappaB, expression of inflammatory cytokines (TNF alpha, IL-1 beta, IL-6, MIP-2 and MCP-1), and provoked a state of reversible myocardial dysfunction, characterized by cardiac dilation, reduced ejection fraction, and decreased end-systolic elastance. CONCLUSION/SIGNIFICANCE: These results are the first to indicate that flagellin has the ability to trigger cardiac innate immune responses and to acutely depress myocardial contractility.

Acute and usual drinking among emergency trauma patients: a study on alcohol consumption and injury patterns.

OBJECTIVE: To investigate the relationship between usual and acute alcohol consumption among injured patients and, when combined, how they covary with other injury attributes. METHODS: Data from a randomised sample of 486 injured patients interviewed in an emergency department (Lausanne University Hospital, Switzerland) were analysed using the chi(2) test for independence and cluster analysis. RESULTS: Acute alcohol consumption (24.7%) was associated with usual drinking and particularly with high volumes of consumption. Six injury clusters were identified. Over-representations of acute consumption were found in a cluster typical of injuries sustained through interpersonal violence and in another formed by miscellaneous circumstances. A third cluster, typical of sports injuries, was linked to a group of frequent heavy episodic drinkers (without acute consumption). CONCLUSIONS: Among injured patients, acute alcohol consumption is common and associated with usual drinking. Acute and/or usual consumption form part of some, but not all, injury clusters.

Assessing multiple sclerosis activity: is the in vitro production of tumor necrosis factor-alpha, interleukins 2, 6, 4, and 10, and immunoglobulin G of value?

Tumor necrosis factor (TNF) alpha, interleukins (IL) 2, 4, 6, and 10, and IgG oligoclonal bands (IgG OB) in vitro production was assessed, after whole-blood stimulation with lipopolysaccharide or concanavalin A, in 61 patients presenting with relapsing-remitting, relapsing-progressive, or chronic progressive multiple sclerosis. Multiple sclerosis patients were receiving no treatment or azathioprine (AZA), cyclosporin, cyclophosphamide, subcutaneous interferon (IFN) beta 1 a, or corticosteroids (CST). Statistical correlations significantly showed that: (a) AZA lowers TNF-alpha (P = 0.002) and increases IL-4 production (P = 0.0024), and IFN-beta 1 a increases TNF-alpha and decreases IL-4 levels; (b) CST has a negative effect on TNF-alpha, IL-6, and IL-4 synthesis; and (c) AZA, IFN-beta 1 a, and CST diminish IgG OB synthesis (P = 0.001). Although our study of the dynamics of TNF-alpha, IL-2, IL-4, IL-6, and IL-10 in vitro production generally found no statistically significant correlations (partly explained by the limited number of values in the various groups), IL-6 was shown to drop during the periods surrounding relapse (P = 0.05) in the absence of treatment, while TNF-alpha (P = 0.04) and IL-6 (P < 0.05) dropped before exacerbation in the presence of AZA. In vitro production of TNF-alpha was closely and positively correlated with that of IL-6, independently of clinical features. The enhanced production of IL-10 detected before or at relapse with AZA and IFN-beta 1 a (trends) may interfere with initiation of the immune reaction and with the development of new CNS lesions. Some discrepancies with previously published results stress the difficulties in studying the state of stimulation of different populations of leukocytes by using a variety of in vitro stimuli and in establishing a correlation between mRNA studies and the amount of final or active protein produced.

Plasma ionized magnesium during acute hyperventilation in humans.

1. Respiratory alkalosis accompanies the clinical syndrome of tetany, precipitates cardiac arrhythmias and predisposes to coronary vasoconstriction. Magnesium plays a critical role in the maintenance of membrane function, and magnesium depletion is often associated with cardiac arrhythmias or vasoconstriction. 2. As technology for detecting circulating ionized magnesium (the most interesting form with respect to physiological and biological properties) is now available in the form of new magnesium-selective electrodes, the effect of respiratory alkalosis induced by voluntary overbreathing for 30 min on circulating ionized magnesium was studied in eight healthy subjects. 3. The total plasma magnesium concentration was not modified by hyperventilation. On the contrary, hyperventilation was associated with a significant reduction in the ionized magnesium concentration of 0.05 (0.02-0.15) mmol/l (median and range) and in the free magnesium fraction of 0.06 (0.01-0.19). During hyperventilation the relative intravascular magnesium mass, calculated from changes in total plasma magnesium concentration and haematocrit, decreased significantly. 4. It is concluded that acute overbreathing reduces the circulating ionized magnesium concentration and the intravascular magnesium mass. It is therefore conceivable that extracellular magnesium deficiency is at least a subsidiary cause of the syndrome of tetany and the cardiac complications that are precipitated by hyperventilation.

Specific situations related to acute schistosomiasis in Pernambuco, Brazil

The present work reports on two epidemiological episodes resulting in acute schistosomiasis involving wealthy persons living in the State of Pernambuco, Brazil. The authors discuss the epidemiological, clinical and serologic characteristics of the acute infections and also the way in which the conditions for transmission occurred.

Is pretreatment with Beta-blockers beneficial in patients with acute coronary syndrome?

OBJECTIVES: The role of beta-blockers in the treatment of hypertension is discussed controversially and the data showing a clear benefit in acute coronary syndromes (ACS) were obtained in the thrombolysis era. The goal of this study was to analyze the role of pretreatment with beta-blockers in patients with ACS. METHODS: Using data from the Acute Myocardial Infarction in Switzerland (AMIS Plus) registry, we analyzed outcomes of patients with beta-blocker pretreatment in whom they were continued during hospitalization (group A), those without beta-blocker pretreatment but with administration after admission (group B) and those who never received them (group C). Major adverse cardiac events defined as composed endpoint of re-infarction and stroke (during hospitalization) and/or in-hospital death were compared between the groups. RESULTS: A total of 24,709 patients were included in the study (6,234 in group A, 12,344 in group B, 6,131 in group C). Patients of group B were younger compared to patients of group A and C (62.5, 67.6 and 68.4, respectively). In the multivariate analysis, odds ratio for major adverse cardiac events was 0.59 (CI 0.47-0.74) for group A and 0.66 (CI 0.55-0.83) for group B, while group C was taken as a reference. CONCLUSIONS: beta-Blocker therapy is beneficial in ACS and they should be started in those who are not pretreated and continued in stable patients who had been on chronic beta-blocker therapy before.

Traitement du décollement de rétine du pseudophaque: étude rétrospective comparant la vitrectomie sans indentation au traitement ab-externo [Vitrectomy without scleral buckle versus ab-externo approach for pseudophakic retinal detachment: comparative retrospective study].

PURPOSE: Retinal detachment (RD) is a major complication of cataract surgery, which can be treated by either primary vitrectomy without indentation or the scleral buckling procedure. The aim of this study is to compare the results of these two techniques for the treatment of pseudophakic RD. PATIENTS AND METHODS: The charts of 40 patients (40 eyes) treated with scleral buckling for a primary pseudophakic RD were retrospectively studied and compared to the charts of 32 patients (32 eyes) treated with primary vitrectomy without scleral buckle during the same period by the same surgeons. To obtain comparable samples, patients with giant retinal tears, vitreous hemorrhage, and severe preoperative proliferative vitreoretinopathy (PVR) were not included. Minimal follow-up was 6 months. RESULTS: The primary success rate was 84% in the vitrectomy group and 82.5% in the ab-externo group. Final anatomical success was observed in 100% of cases in the vitrectomy group and in 95% of cases in the ab-externo group. Final visual acuity was 0.5 or better in 44% of cases in the vitrectomy group and 37.5% in the ab-externo group. The duration of the surgery was significantly lower in the ab-externo group, whereas the hospital stay tended to be lower in the vitrectomy group. In the vitrectomy group, postoperative PVR developed in 3 eyes and new or undetected breaks were responsible for failure of the initial procedure in 2 eyes. CONCLUSION: Primary vitrectomy appears to be as effective as scleral buckling procedures for the treatment of pseudophakic RD.

Acute Damage to the Posterior Limb of the Internal Capsule on Diffusion Tensor Tractography as an Early Imaging Predictor of Motor Outcome after Stroke

Background and Purpose Early prediction of motor outcome is of interest in stroke management. We aimed to determine whether lesion location at DTT is predictive of motor outcome after acute stroke and whether this information improves the predictive accuracy of the clinical scores. Methods We evaluated 60 consecutive patients within 12 hours of MCA stroke onset. We used DTT to evaluate CST involvement in the MC and PMC, CS, CR, and PLIC and in combinations of these regions at admission, at day 3, and at day 30. Severity of limb weakness was assessed using the m-NIHSS (5a, 5b, 6a, 6b). We calculated volumes of infarct and FA values in the CST of the pons. Results Acute damage to the PLIC was the best predictor associated with poor motor outcome, axonal damage, and clinical severity at admission (P&.001). There was no significant correlation between acute infarct volume and motor outcome at day 90 (P=.176, r=0.485). The sensitivity, specificity, and positive and negative predictive values of acute CST involvement at the level of the PLIC for 4 motor outcome at day 90 were 73.7%, 100%, 100%, and 89.1%, respectively. In the acute stage, DTT predicted motor outcome at day 90 better than the clinical scores (R2=75.50, F=80.09, P&.001). Conclusions In the acute setting, DTT is promising for stroke mapping to predict motor outcome. Acute CST damage at the level of the PLIC is a significant predictor of unfavorable motor outcome.