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Health professionals are currently facing the challenge of managing an increasing number of old patients presenting with acute stroke, due to rapid aging of the population. Compared to their younger counterparts, elderly patients differ in many ways in the setting of acute stroke. Apart from a striking high stroke incidence, which increases exponentially as age increases, cardioembolism also becomes, as patients age, the main cause of ischemic stroke. Delirium, which can challenge the diagnosis, is frequent at the acute phase of stroke, and may be related to an underlying dementia, which is almost exclusively observed in the elderly during stroke. At all levels, management of elderly stroke patients is suboptimal, especially when they are cognitively impaired, with insufficiencies including admission to stroke units, applying standards of care and investigation, reperfusion therapy for ischemic stroke, and finally transfer to rehabilitation centers. A paradigm shift must take place to limit age-related discrimination for acute-phase management of stroke.

To evaluate the safety and visual outcomes of intrastromal corneal ring segment (ICRS) implantation followed by transepithelial phototherapeutic keratectomy (te-PTK) and corneal cross-linking (CXL) in patients with mild keratoconus.Patients with mild keratoconus and contact lens intolerance who underwent sequential ICRS implantation followed by phototherapeutic keratectomy and corneal CXL between April 2015 and July 2018 were retrospectively included in the study. Refractive and visual outcomes, satisfaction questionnaire and complications were recorded at the last follow-up (mean 9.5 months postoperatively).Twenty eyes of 17 patients were enrolled, including 5 women and 15 men. The mean time between the two procedures was 16 months. Based on values before the first procedure and 9.5 months after the second procedure, significant improvements were noted in uncorrected distance visual acuity (UDVA) (0.80±0.35 logMAR vs. 0.46±0.38 logMAR), corrected distance visual acuity (CDVA) (0.38±0.23 logMAR vs. 0.13±0.16 logMAR), maximal K (56.11±4 diopters [D] vs. 50.6±3.56 D), mean K (51.87±3.43 D vs. 48.45±2.91 D), cylinder (7.99±3.94 D vs. 4.23±3.49 D), and spherical equivalent (-3.84±3.36 D vs. -0.99±2.15 D) (P0.01). Among the outcomes, we noted 5 (25%) superficial corneal scarring (haze); 75% of eyes gained=1 logMAR line of CDVA. In all, 94.5% of patients reported that they were satisfied with their outcomes.Combining ICRS implantation followed by te-PTK and corneal CXL appears to be a safe and effective approach for improving visual outcomes and quality of life in keratoconus patients.

The thrombus causing a stroke can be seen on the susceptibility weighted angiography (SWAN) magnetic resonance imaging (MRI) sequence. But it is very small and hard to detect by humans. Up to date the thrombus is identified by trained human experts. But as stroke needs quick treatment, an automatic detection of the thrombus would be useful to speed up the diagnosis of acute stroke. We propose a method for automatic thrombus detection from SWAN using three separate U-Nets which work on the axial, coronal and sagittal planes.

BACKGROUND Bradykinin-mediated angioedema (AE) is a complication associated with thrombolysis for acute ischemic stroke. Risk factors are unknown and management is discussed. OBJECTIVES To clarify risk factors associated with bradykinin-mediated AE after thrombolysis for acute ischemic stroke. METHODS In a case-control study conducted at a French reference centre for bradykinin angiœdema, patients with thrombolysis for acute ischemic stroke and a diagnosis of bradykinin-mediated angiœdema, were compared to controls treated with thrombolysis treatment without angiœdema. RESULTS Fifty-three thrombolysis-related AE were matched to 106 control subjects. The sites of attacks following thrombolysis for ischemic stroke mainly included tongue (34/53, 64%) and lips (26/53, 49%). The upper airways were involved in 37 (70%) cases. Three patients required mechanical ventilation. Patients with bradykinin-mediated angiœdema were more frequently women [33 (62%) vs. 44 (42%); P = 0.01], had higher frequency of prior ischemic stroke [12 (23%) vs. 9 (8%); P = 0.01], hypertension [46 (87%) vs. 70 (66%); P = 0.005], were more frequently treated with angiotensin-converting enzyme inhibitor [37 (70%) vs. 28 (26%); P

Low-level radioactive surface-contamination measurements require lightweight, large-area, and high-efficiency detectors. In the previous work, we utilized wavelength shifting (WLS) fibers, coupled to a beta-sensitive plastic scintillator (PS) layer on one side, and to an alpha-sensitive ZnS(Ag) layer on both sides, for detecting both alpha and beta particles. In this work, the main goal was to improve the light collection (maximizing the number of photons reaching the PMT) by optimizing the WLS fibers structure, for getting better signal-to-noise ratio and to minimize the low-energy threshold of the detector. In most cases, improving the light collection mostly influenced the detector resolution. In our case, improving the light collection will improve the detection efficiency by ability to detect more events at low-energy spectrum, which is limited by the noise level. Aiming to improve the scintillation light-collection efficiency, we investigated and compared four different detector configurations. Two of them described in the previous work presents utilization of WLS fibers, with different diameters ( $1~\hbox{mm}\phi $ , $1.5~\hbox{mm}\phi $ ), coupled on the PS. Two other configurations present utilization of WLS fibers ( $1.5~\hbox{mm}\phi $ ) installed into a flat groove on the PS layer, while in one configuration we utilized straight WLS fibers and in the other we utilized bent WLS fibers. It was found that the utilization of WLS fibers in bent configuration gives the highest light-collection efficiency. Additionally, there is improved light collection achieved by using WLS fibers with wider diameter ( $1.5~\hbox{mm}\phi $ ), which maximizes the capture fraction. Additionally, since ZnS(Ag) and PS have different decay times (200 ns and 2.4 ns, respectively), we were able to separate alpha from beta events. An algorithm script was developed to calculate the full width at half maximum (FWHM) of each pulse and a histogram was generated of the FWHM values for the pulse shape discrimination (PSD). Efficient PSD was achieved for alpha energies above 100 keV with figure of merit (FOM) of 1.92. GEANT4 simulation was carried out and compared with experimental results. The results of both were matched, showed that the light-collection efficiency from the bent WLS fibers configuration was the best. The simulation results and the experiments, including full description of the detector structure, ionization stage, and the WLS light collection, are presented.

Low level radioactive surface contamination measurements require lightweight, large area and high efficiency detector. In most existing scintillation detectors there is a tradeoff between effective area and scintillation light collection. By using wavelength shifting (WLS) fibers the scintillation light may be collected efficiently also in a large area detector. In this study, WLS fibers were coupled to a beta sensitive plastic scintillator layer and to a alpha sensitive silver-activated zinc sulfide ZnS(Ag) layer for detecting both alpha and beta particles. The WLS fibers collect the scintillation light from the whole detector and transfer it to a single PMT. This first prototype unique configuration enables monitoring radioactive contaminated surfaces by both sides of the detector and provides high gamma rejection. In this paper, the detector structure, as well as the detector’s measured linear response, will be described. The measured detection efficiency of 238 Pu alpha particles (5.5 MeV) is ~63%. The measured detection efficiency for beta particles is ~89% for 90 Sr– 90 Y (average energy of 195.8 keV, 934.8 keV), ~50% for 36 Cl (average energy of 251.3 keV), and 35% for 137 Cs (average energy of 156.8 keV).

This study aimed to describe the prevalence of overweight (excluding obesity) and obesity, and distribution of waist circumference, in children and adults in four French Overseas Territories (Guadeloupe, Martinique, French Guiana in the Caribbean and French Polynesia in the Pacific Ocean).The survey was designed to provide a sample representative of the population in each of the four territories. The protocol aimed to evaluate 600 adults (aged ≥ 15 years) and 300 children (aged: 5-14 years) in each territory.In children, the differences were small among the territories in the prevalence of overweight (excluding obesity), as defined by the International Obesity Task Force (IOTF): Guadeloupe, 15.4%; Martinique, 17.0%; French Guiana, 13.2%; and French Polynesia, 17.2% (P = 0.49). Larger, significant, differences were observed for obesity, with prevalences of 7.2%, 7.7%, 5.4% and 15.9%, respectively (P0.002). In adults, the prevalence of obesity also differed significantly among the territories: 22.9%, 22.0%, 17.9% and 33.1% in Guadeloupe, Martinique, French Guiana and French Polynesia, respectively (P0.001, adjusted for age and gender). However, overweight (excluding obesity) was again more homogeneously distributed, with prevalences of 31.7%, 33.6%, 30.3% and 34.4%, respectively (P = 0.43, adjusted for age and gender). Waist circumference was larger in French Polynesia than in the other territories in both genders, and in both children and adults.While the distribution of overweight was relatively homogeneous, the prevalence of obesity differed considerably across the four territories. It was especially high in French Polynesia, and in children and women. Appropriate programmes are urgently needed in these populations, especially in children, to avoid the morbidity associated with obesity.

Resume La prise en charge de l’astigmatisme irregulier par des anneaux intra corneens est une technique additive intra stromale developpee initialement pour traiter la myopie mais finalement utilisee pour corriger les effets refractifs deleteres des ectasies corneennes post LASIK ou du Keratocone. Ils sont indiques en cas d’intolerance au port de lentilles rigides en alternative a l’allogreffe corneenne. Leur mecanisme d’action est complexe et met en jeu des remaniements biomecaniques aboutissant au recentrage et a l’aplatissement de l’ectasie. La mise en œuvre chirurgicale est grandement facilitee grâce a l’usage du laser femtoseconde. Les strategies d’implantations, personnalisees en fonction du profil topographique et tomographique de chaque patient, sont en constante evolution. La refraction et la vision sont ainsi ameliorees dans plus de 70 % des cas. Les complications restent exceptionnelles. La combinaison des anneaux intra corneens avec d’autres corneoplasties est souvent possible, le plus souvent de maniere sequentielle, afin d’optimiser les resultats fonctionnels.

Resume Objectif Discuter les differents profils d’ablation en chirurgie refractive, leurs caracteristiques techniques, les resultats cliniques et leurs limitations. Materiel et methodes Revue de la litterature. Resultats Avec l’emergence de la technologie basee sur le front d’onde, de nouveaux profils de photoablation ont ete developpes, permettant la personnalisation des traitements refractifs et la diminution des symptomes visuels nocturnes qui entachaient la reputation des chirurgies refractives. De nombreuses etudes comparant ces nouveaux traitements ou les differentes plateformes excimer ont ete publiees dans la litterature ces dix dernieres annees. Cependant, ces nouveaux algorithmes de traitement ont-ils demontre une reelle superiorite par rapport au traitement conventionnel en termes de performances visuelles ? Conclusion Malgre les avancees technologiques, et l’amelioration des resultats visuels par les photoablations personnalisees par rapport aux photoablations conventionnelles, la promesse de l’excellence en termes de performance visuelle n’a pas encore ete atteinte avec ces differentes technologies. L’emergence d’une nouvelle technologie basee sur le « ray tracing » est actuellement en cours d’etude et pourrait theoriquement produire un profil d’ablation personnalisee ideal.

Introduction La thrombolyse a revolutionne le pronostic de l’accident vasculaire cerebral ischemique (AVC). L’angiœdeme (AO) est une complication rare mais potentiellement letale de la thrombolyse. L’incidence de ces AO est variable en fonction des etudes, variant de 1,3 a 7,9 % [1] . Ces donnees sont issues d’etudes retrospectives avec des effectifs faibles et leurs resultats sont parfois contradictoires. Patients et methodes Il s’agit d’une etude retrospective nationale multicentrique. Cent vingt-sept unites neurovasculaires (UNV) ont ete contactees par mail. Les caracteristiques demographiques et les donnees cliniques de ces patients ont ete recueillies. L’AO bradykiniques etait defini par la survenue apres la thrombolyse d’un œdeme non provoque de la langue, des levres ou de l’oropharynx. L’AO etait attribue a la thrombolyse lorsqu’il succedait a l’initiation de ce traitement et lorsqu’il n’avait pas les caracteristiques d’un AO histaminique. Resultats Soixante-treize reponses ont ete obtenues (57,5 % des UNV). Vingt centres ont pu retrouver 43 cas qui ont ete analyses. L’AO post-thrombolyse etait plus frequemment retrouve chez des femmes (55,8 % des cas). La moyenne d’âge etait de 73 ans et les patients etaient d’origine europeenne. Dans 3 cas (0,07 %), il existait un antecedent personnel d’AO bradykinique. Des antecedents d’allergie etaient retrouves dans 0,07 % des cas. Il s’agissait du premier episode d’AVC dans 79 % des cas. Un diabete etait rapporte dans 20,9 % des cas avec un traitement par gliptine chez 3 patients (0,07 %). Parmi les patients, 81,4 % etaient hypertendus. Sur les 43 patients, 29 (67,4 %) etaient traites par IEC (principalement perindopril [41,4 %] et ramipril [27,6 %]), 2 par sartan (0,05 %) et 13 (30,2 %) par betabloquants (en majorite du bisoprolol dans 69,2 % des cas). L’AVC concernait le territoire sylvien dans 90,7 % des cas sans predominance droite ou gauche. Le NIHSS etait en moyenne a 11. Le delai moyen entre l’AVC et la thrombolyse etait de 166,6 min. L’AO survenait en moyenne 115,4 min apres le debut de la thrombolyse et la duree moyenne rapportee de l’episode etait de 21,2 h. Dans 18 cas (41,9 %), il concernait uniquement la langue, dans 8 cas (18,6 %) uniquement les levres et dans 9 cas (20,9 %) la levre et la langue. Dans 2 cas (0,05 %), il existait un œdeme du pharynx qui etait associe a un œdeme de la levre pour un cas et un œdeme de la levre et de la langue pour l’autre cas. Dans 4 cas une atteinte du visage etait rapportee (0,09 %) associe dans 2 cas a une atteinte labiale. Dans les autres cas nous ne disposions pas de la localisation. Lorsque cette donnee etait rapportee (79 % des cas), l’AO etait asymetrique dans la majorite des cas (64,7 %) et etait preferentiellement ipsilateral au deficit (controlateral a la localisation de l’AVC) dans 81,8 % des cas. Douze patients (27,9 %) ont ete hospitalises en reanimation et 4 patients (0,09 %) ont ete intubes et ventiles mecaniquement. Aucune necessite de tracheotomie n’a ete relevee. Deux deces (0,05 %) etaient rapportes a j15 et j19 et non lies a l’AO. Trente-trois patients ont recu des corticoides par voie veineuse (76,7 %), 23 des antihistaminiques (53,5 %) et 6 de l’adrenaline par voie veineuse (14,0 %). Dix patients (23,2 %) ont beneficie d’un traitement specifique par icatibant (50 % des cas) ou concentre de C1 inhibiteur (50 % des cas). Dans 1 cas (0,02 %) de l’acide tranexamique a ete introduit. Six patients n’ont recu aucun traitement (14,0 %). Les IEC ont ete poursuivis apres la sortie chez 10 patients (23,2 %) et introduits pendant l’hospitalisation chez 4 patients (0,09 %). Discussion Cette analyse, sur un effectif superieur aux etudes precedemment rapportees, suggere un lien entre IEC et AO post-thrombolyse ce qui n’avait pas ete retrouve dans une meta-analyse [1] mais etait deja souligne par plusieurs etudes retrospectives [2] , [3] . Elle confirme que l’AO est le plus souvent ipsilateral au deficit et majoritairement peu severe avec cependant possibilite d’engager le pronostic vital [2] . Conformement a la litterature, les corticoides et les antihistaminiques sont le plus souvent utilises malgre leur inefficacite sur cet AO bradykinique et un traitement specifique n’est introduit que dans 23,2 % des cas. Conclusion L’AO est une complication potentiellement dangereuse de la thrombolyse et les IEC sont un facteur de risque. Sa reconnaissance precoce et l’information des neurologues pourraient permettre d’initier rapidement un traitement specifique. Une etude prospective est necessaire afin de mieux connaitre son incidence et ses caracteristiques clinicobiologiques.

Backgrounds: The severity of envenoming from Bothrops lanceolatus is determined by the development of cerebral, myocardial or pulmonary infarctions, and occasionnaly by serious local envenoming. Introduction of specific antivenom has resulted in a dramatic improvement in the prognosis of this envenoming. Against this background, we report 3 recent cases of patients bitten by B. lanceolatus who developed cerebral infarctions despite early administration of antivenom. Methods: In 1991 a protocol was designed to apply the same evaluation and treatment to all envenomed patients. The clinical results have been continuously monitored. Results: Between April 1993 and July 2003, 128 envenomed patients (age 6–83 (mean 45) years) were treated. No coagulopathy, thrombotic complication or death occurred in patients who were given early antivenom therapy—up to 6 h following the bite—and 126 patients recovered. Between August 2003 and October 2004, 10 additional patients (18–66 (mean 46) years) were given antivenom at the time of admission at hospital. Of these, 3 developed cerebral infarctions within 24 h. Effectiveness of antivenom was tested on mouse, and found to be lower than specified by the manufacturer. Discussion: Our data shows that recently the antivenom may have lost some of its efficacy. Possible mechanisms include variability in venom composition or loss of activity of the antibodies produced more than 15 years ago. The question is whether we should attempt to produce improved antivenom. This could include activity against the venom of Bothrops caribbaeus from the neighbouring island of St Lucia, which shares a monophyletic group with B. lanceolatus and whose venom produces a similar thrombotic syndrome. Conclusion: Prevention of systemic vessels thrombosis remains the main therapeutic challenge of B. lanceolatus envenoming in Martinique.

Objective To assess the efficacy and safety of lamivudine, an antiviral agent that strongly inhibits hepatitis B virus (HBV) DNA replication, combined with plasma exchanges after short-term corticosteroids for HBV-related polyartertitis nodosa (PAN). Methods Ten patients (8 men, 2 women, mean ± SD age 50.4 ± 14.4 years) with previously untreated HBV-related PAN were included in a multicenter, prospective, observational trial. Oral prednisone (1 mg/kg/day) was given for 1 week, then tapered and withdrawn within 1 week. Then, lamivudine (100 mg/day or less in the case of renal insufficiency) was started for a maximum of 6 months. Plasma exchanges were performed simultaneously and scheduled as follows: 3/week for 3 weeks, 2/week for 2 weeks, then 1/week until hepatitis B e antigen (HBeAg) to anti-HBe antibody (HBeAb) seroconversion was obtained or until 2–3 months of clinical recovery was sustained. The primary trial endpoint was clinical recovery from HBV-PAN at 6 months. The secondary endpoint was loss of detectable serum HBeAg and HBV DNA, and HBeAg to HBeAb seroconversion at 9 months. Results One death, attributed to catheter-related septicemia, was recorded. At 6 months, all 9 survivors had achieved clinical recovery and by 9 months, 6 of 9 (66%) had seroconverted. Conclusion The strategy of short-term steroids followed by lamivudine and plasma exchanges effectively led to recovery from HBV-PAN. Because of its oral administration and good safety profile, lamivudine should henceforth be considered the antiviral agent of choice to treat HBV-related PAN.

Introduction/objectifs/but La plateforme de telemedecine ORTIF se deploie en Ile de France depuis janvier 2015. Elle permet aux professionnels de realiser des tele-expertises et parfois des visioconsultations. Quel est l’impact sur la prise en charge des accidents vasculaires cerebraux (AVC) ? Materiel et methode Le service de neurologie de l’hopital Sud Francilien est le centre de reference d’un territoire comprenant 600 000 habitants. Il prend en charge plus de 900 patients victimes d’AVC par an, realise plus de 350 thrombolyses par an completees eventuellement par une thrombectomie sur l’hopital de Bicetre. Il fonctionne en lien avec 9 etablissements accueillants des urgences. Six de ces structures sont progressivement equipees d’ORTIF. Nous evaluons le recours a l’expertise neurologique par telemedecine pour les AVC de ce territoire pilote entre janvier et aout 2016. Resultats/observations Cent quatre-vingt-douze patients suspects d’AVC ont pu beneficier d’une expertise neurologique avec ORTIF : Melun (53), Etampes (48), Montereau (41), Fontainebleau (17), Longjumeau (14), Nemours (12), Dourdan (6). Une thrombolyse a ete effectuee chez 22 d’entre eux dont 11 sur site. Bien qu’encourageants, ces resultats ne refletent pas suffisamment l’activite potentielle de telemedecine dans ce contexte. L’engagement des directions de service et une experience prealable de visioconference sont identifies comme facteurs favorisant l’utilisation de ces outils. La protocolisation, la realisation de telestaffs interservices debutes il y a quelques mois et la mise en œuvre d’un protocole territorial d’imagerie sont les actions mises en œuvre pour impulser les usages. La conduite du changement des professionnels est affaire d’implication de chacun des acteurs et des leaders d’opinion locaux.

Late evolution of peripheral arterial disease consists in the apparition of critical limb ischemia. Surgical treatments allow to treat these patients during long time; however, in most patients, especially the diabetic ones, there a very few options and the clinical evolution is rapidly dramatic. For these reasons, the critical limb ischemia is one of the first diseases treated by genic or cellular therapies aiming to improve blood flow perfusion in the lower-limbs. In this short review, we describe the main clinical trials of genic therapy; most of them have been abandoned because serious side effects, modest effects and major risks. Different types of stem cells are now used for cell therapy: endothelial progenitor cells, early or late, activated or not, mesenchymal stem cells, embryonic stem cells and human induced pluripotent stem cells. Problems of characterization are described and the results of the most important clinical trials are reported.

Resume Les dossiers de 64 cas (53 hommes et 11 femmes) d'envenimation par le B. Lanceolatus ont ete etudies retrospectivement. Une coagulopathie etait observee chez 15 patients (23,4 p. 100) : quatre patients avaient une thrombopenie isolee, 11 avaient des troubles de la coagulation evoquant une coagulation intravasculaire disseminee. Des complications hemorragiques etaient notees chez deux patients (3,1 p. 100). Des complications thrombotiques survenaient chez 18 patients (28,1 p. 100) dans un delai de 24 ± 14 heures apres la morsure, malgre une heparinotherapie prescrite d'emblee : infarctus du myocarde (IDM) (5 cas), embolie pulmonaire (EP) (1 cas), accident vasculaire cerebral ischemique (AVC) (7 cas), thrombose de l'artere femorale (1 cas), IDM et AVC (2 cas), IDM et EP (1 cas), necrose extensive des parties molles (1 cas). Une coagulopathie existait chez 10 de ces 18 malades et chez cinq des 46 malades n'ayant pas presente de thromboses. Cette etude suggere que les thromboses severes observees apres la morsure du B. Lanceolatus pouvaient se produire avec ou sans coagulopathie associee et que la coagulopathie n'etait pas la cause principale de ces thromboses.

Management of irregular astigmatism with intracorneal rings segments is an intrastromal additive technique developed initially for myopia but eventually popularized for keratoconus and post LASIK ectasia. ICR's are indicated for rigid contact lens intolerance, as an alternative to corneal transplantation. The mechanism of action is complex and involves biomechanical changes leading to a centering and a flattening of the ectasia. The surgical procedure has become much easier thanks to the use of femtosecond lasers. Individualized implantation strategies, based on each patient's topographic and tomographic pattern, are constantly evolving. Patients' refraction and vision are usually improved in more than 70% of cases. Complications remain very rare. Intracorneal ring segments can often be combined with other types of keratoplasty, usually in a sequential fashion, so as to optimize functional results.

To provide an overview of the clinical results of various ablation profiles and discuss their technical characteristics and limitations.Literature review.With the emergence of wavefront technology, new photoablation profiles have been developed, allowing for customization of refractive treatments and reduction of nocturnal visual symptoms, which adversely affect the reputation of refractive surgery. Over the past decade, several comparative studies have been published in the literature aiming to demonstrate either the superiority of wavefront-guided correction over conventional, or one laser platform over another. However, has an ideal treatment algorithm really emerged from these studies? Does one ablation profile clearly demonstrate superiority over another, in terms of visual performance?Despite technological advances as well as improved visual results for custom versus conventional photoablation, the promise of excellence in visual performance has not been achieved with these various technologies. The concept of an individualized eye model has emerged recently, based on an optical ray tracing algorithm, and could theoretically provide an ideal ablation profile, thus fulfilling the promise of "supernormal vision".

Hydroxyethyl starches (HES) could differ with regard to the origin, and the influence on the coagulation of the raw material is unknown. This study compared the effects of a new potato-derived HES with a maize-derived HES and two crystalloid solutions.Whole blood from 10 healthy individuals was diluted by 20% and 40% using either non-balanced potato-derived HES 130/0.42/6:1, non-balanced maize-derived HES 130/0.4/9:1, isotonic saline or Ringer's lactate solution. Samples were analysed by thromboelastometry ROTEM(®) : Coagulation was initiated by acid ellagic [intrinsic thromboelastometry (INTEM)] or tissue factor (extrinsic thromboelastometry) with and without cytochalasin to determine the functional component of fibrinogen [cytochalasin-d-modified thromboelastometry (FIBTEM)]. Platelet count and fibrinogen activity were measured.No effect of raw material was found as no difference was detected among the HES solutions. Whatever the solution, progressive haemodilution impaired haemostasis in a dose-dependant manner: For INTEM, the clot formation time was increased up to 308% and the maximum clot firmness (MCF) was decreased down to 49%. As dilution increased, initiation of coagulation was also impaired. Thromboelastometric alterations were more severe with HES than with crystalloids, especially regarding fibrin polymerization explorations: MCF of FIBTEM was considerably reduced from 12[10-14] to 2[2-3] mm (P0.05). Fibrinogen activity and platelet count were reduced by dilution in a dose-dependant manner and decreased similarly in all groups.Maize- and potato-derived HES have similar effects on coagulation. Both the starch preparations tested lead to more severe haemostatic defects than crystalloids, and impairment of fibrin polymerization appears to be a leading determinant of this coagulopathy.

Involvement of intracranial arteries in giant cell arteritis is a rare condition but often carries a fatal prognosis. Corticosteroids seem to be insufficient to avoid ischemic cerebral complications, and could even promote the occurrence of stroke. We report the case of a patient with giant cell arteritis who experienced recurrent cerebellar stroke caused by intracranial vertebrobasilar stenoses with a favorable outcome following treatment.A 77-year-old woman presented with a 3-month history of impaired general condition. She had new-onset headaches, jaw claudication and transient vertigo, especially when she woke-up. The brain MRI showed a recent cerebellar infarction. One week later, she was hospitalized for a clinical deterioration related to a recurrent cerebellar stroke caused by intracranial vertebro-basilar stenoses. Giant cell arteritis was confirmed on the temporal artery biopsy. A treatment with high-dose oral corticosteroids was begun associated with an intensive antiplatelet therapy. The clinical outcome was favorable with rapid improvement of gait imbalance together with a complete radiological regression of the intracranial stenoses.Ischemic stroke in giant cell intracranial arteritis is a severe condition without a well-defined treatment. Corticosteroid therapy improves intracranial stenoses caused by vasculitis but should be initially associated with an intensive antithrombotic therapy to avoid early recurrence of cerebral infarcts.

Resume Introduction La paralysie periodique thyreotoxique est habituellement decrite au sein des populations asiatiques. Elle est rare chez le caucasien, et exceptionnelle dans la race noire. Exegese Nous rapportons deux cas de tetraplegie hyporeflexique generalisee avec hypokaliemie. Dans le premier cas, l'hyperthyroidie est decouverte a cette occasion, et l'apparition de complications respiratoires et cardiaques conduit a un transfert en reanimation. Dans le second cas, alors que l'hyperthyroidie est connue mais decompensee par insuffisance therapeutique, les signes neurologiques regressent spontanement. Conclusion Devant tout acces paralytique hypokaliemique, un controle des hormones thyroidiennes est requis, meme en l'absence de tous signes peripheriques, et ce quelle que soit la race.

Neurological involvement associated with copper deficiency has been reported recently in humans and may be under-recognized.A 65-year-old patient, with past history of gastrectomy 40 years earlier, developed a myelodysplastic syndrome and then subacute onset of progressive gait ataxia and paresthesias in the lower extremities. Serum vitamin B12 level was low but neurological deterioration persisted, despite vitamin replacement therapy and normal cobalamin level. Further diagnostic investigations revealed severe copper deficiency. Copper supplementation led to hematologic improvement and neurological stabilization.Copper and vitamin B12 deficiency, due to malabsorption as a cause of progressive neuromyelopathy and hematologic manifestations, may coexist.

Cannabis is the most consumed drug in the world particularly in young adults. Few reports have suggested a causal role of cannabis in the development of cerebral or cardiovascular events. We describe the first association of myocardial infarction and stroke after heavy cannabis consumption in a 45-year-old woman.Stroke occurred in relation with a right carotid and middle cerebral artery thrombosis after cannabis abuse. The patient was successfully treated with intravenous rt-PA. Two days after her admission, she presented a myocardial infarction due to a coronary thrombosis. Cerebral and coronary arteries were angiographically normal. Etiological tests were negative and a toxic cause in relation with cannabis consumption was concluded.Cannabis can be associated with vascular events by different mechanisms. Thrombosis may occur in cerebral and/or coronary arteries. We suggest that it might be useful to search for cannabis consumption systematically in young subjects victims of stroke and myocardial infarction.

Giant cell arteritis is the most frequent vasculitis and can cause stroke in about 4% of the patients. The mechanism is often hemodynamic in relation with an arterial stenosis or occlusion. Optimal treatment remains to be defined. Outcome is often poor.We report the case of a 78-year-old patient, with giant cell arteritis who developed neurological deterioration after the onset of the corticotherapy. Brain MRI revealed bilateral stroke caused by multiple preocclusive internal carotid stenosis. The patient was treated successfully with angioplasty and stenting.Endovascular treatment could constitute an interesting alternative for patients with giant cell arteritis associated with neurological deterioration after a first episode of stroke because of hemodynamic instability or at stroke recurrence. For these patients, the usual medical treatment appears to be insufficient.

Data on epidemiology of neuromyelitis optica (NMO) remained scarce in the last century, but the recent development of diagnostic criteria now enables inclusion of both monophasic and relapsing NMO in epidemiologic studies. Given the rarity of NMO, multicentric studies are needed to confirm a presumed higher frequency in women and in populations of black/Asian ancestry. The Caribbean basin is a suitable area for collecting a large NMO cohort and to assess the prevalence, incidence, and mortality of this disorder.This population-based survey of the NMO spectrum in the French West Indies (FWI) and Cuba included 151 cases.Ninety-eight patients (female/male ratio: 9.8) had NMO. Age of onset in NMO patients was 30.9 years. Mean annual incidence of NMO in the French West Indies for the period July 2002 to June 2007 was 0.20/100,000 inhabitants (IC 95% 0.05-0.35). Incidence rates were steady in the FWI during the 1992 to 2007 period. Decreasing mortality in the FWI during the 1992 to 2007 period explained the increasing prevalence which was 4.20/100,000 inhabitants (IC 95% 3.7-5.7) in June 2007. The prevalence of NMO in Cuba on November302004 was 0.52/100,000 inhabitants. (IC 95% 0.39-0.67). Prevalence rates did not differ significantly by ethnic group in Cuba, however, black Cubans exhibited the highest prevalence.Epidemiologic studies on NMO in each population are needed to determine whether aggressive therapies can reduce the mortality of this devastating disorder.In the Caribbean basin, NMO involves almost exclusively young women; the epidemiologic data confirm its predilection for populations of African ancestry. In the FWI, recent and aggressive therapy has lowered mortality but with an increase in the prevalence of NMO.

Ingestion of star fruit (Averrhoa carambola) can induce severe intoxication in subjects with chronic renal failure. Oxalate plays a key role in the neurotoxicity of star fruit. We report the cases of two patients with unknown chronic renal insufficiency who developed severe encephalopathy after ingestion of star fruit. The two patients developed intractable hiccups, vomiting, impaired consciousness and status epilepticus. Diffusion-weighted MR imaging showed cortical and thalamic hyperintense lesions related to epileptic status. They improved after being submitted to continuous hemofiltration which constitutes the most effective treatment during the acute phase.

There are few reports of amyloidosis diagnosed by deliberate biopsy of accessory salivary glands. Usually, a biopsy performed for dry mouth syndrome reveals an unsuspected amyloidosis. We report the case of 2 patients with lambda-type light chain monoclonal gammapathy complicated by generalized amyloidosis and in whom biopsy of the accessory salivary glands showed signs of amyloidosis. In the first patient accessory salivary gland biopsy was performed because these glands were enlarged, and the monoclonal dysglobulinaemia was subsequently diagnosed by serum immunoelectrophoresis. In the second patient with nephrotic syndrome, renal biopsy could not be carried out owing to the presence of a renal malformation; amyloidosis was confirmed by periumbilical fat aspiration, and a systematic biopsy of accessory salivary glands also showed evidence of amyloidosis. Biopsy of accessory salivary glands seems to be a particularly simple and safe method to detect generalized amyloidosis in patients with chronic inflammatory disease or monoclonal dysglobulinaemia.

Few neurological diseases are linked with anti-glutamic acid decarboxylase antibodies (GAD-ab); stiff man syndrome is an example. Cerebellar ataxia is a new feature of this expanding spectrum. No therapeutic trial is yet available in these diseases. We here report on four patients suffering from cerebellar ataxia linked with GAD-ab and review the data in the literature on this recently described syndrome.We conducted an open trial with monthly pulsed steroids. Steroid pulses were given six months followed with placebo for another six months. Main clinical and biological parameters were monitored monthly (International Cooperative Cerebellar Ataxia Rating Scale [ICARS] and GAD-ab).The clinical response was found limited and inconstant. Transient decline in GAD-ab level was noted in two patients. Moreover, GAD-ab level was found highly variable and did not correlate with clinical parameters.Cerebellar ataxia with GAD-ab is an increasingly described syndrome. Outcome can be severe, leading to definitive cerebellar atrophy. Diagnosis is supported by high level of serum GAD-ab with intrathecal secretion. Experimental data have suggested a direct excitotoxic effect of GAD-ab on Purkinje cells. Response to various treatments is often disappointing. Improvement has been obtained with veinoglobulins in individual patients. A weak clinical and biological response was associated with monthly steroid pulses.

Neuromyelitis optica (Devic's disease, NMO) is an inflammatory disease of the central nervous system preferentially involving the spinal cord and optic nerves in either a monophasic or relapsing-remitting course. B-cell induced pathogenesis was recently described for NMO. Rituximab is a chimeric monoclonal antibody directed against the CD20 antigen, which causes depletion of B-cells. Rituximab might be effective in treatment of NMO. We report the two-year clinicoradiological and biological follow-up data from a patient included in July 2005 in a prospective trial of rituximab for severe NMO refractory to immunosuppressant therapy. Blood B-cell depletion after rituximab induction was maintained for 10 months. Seven attacks occurred during a two-year follow-up. EDSS increased from 7.0 to 8.0. Left visual acuity decreased from 20/20 degrees to 20/60 degrees. Spinal cord atrophy worsened.

Resume Introduction . — Les effets secondaires des immunoglobulines intraveineuses a fortes doses sont le plus souvent benins. Cependant, des cas d’insuffisance renale aigue et plus rarement d’infarctus cerebral ont ete decrits. Il n’y a pas a notre connaissance de cas rapporte cumulant ces deux types de complications severes. Exegese . — Une insuffisance renale aigue severe et un infarctus de l’artere choroidienne anterieure droite sont survenus simultanement 2 jours apres une cure d’immunoglobulines intraveineuses a 2 g/kg chez un patient purpura thrombopenique idiopathique. De plus, l’infarctus cerebral s'est aggrave a la suite d’une seconde cure d’immunoglobulines intraveineuses a 1 g/kg. Une etude clinique et neuroradiologique a ete realisee chez ce patient. Conclusion . — Un traitement par immunoglobulines intraveineuses a fortes doses necessite une surveillance rigoureuse de la fonction renale et la limitation des doses pour eviter la survenue d’un accident thrombotique.

Resume Sujet de l'etude Un cas d'encephalomyelite aigue disseminee (EAD) precedant l'apparition d'un lupus cutane est rapporte. Objectifs Suggerer un lien physiopathologique entre l'EAD et le lupus cutane. Resume des connaissances actuelles Les complications neurologiques du lupus erythemateux dissemine sont frequentes. Cependant, les manifestations neurologiques centrales de nature demyelinisantes sont rares, limitees a la neuromyelite optique (NMO). La NMO est consideree comme une forme partielle d'EAD. Methodes Une etude clinique, neuroradiologique et immunologique a ete realisee dans notre cas. Resultats Une EAD a ete diagnostiquee chez une jeune femme noire. Trois ans plus tard, elle avait developpe un lupus cutane, sans manifestations systemiques et avec une complementemie normale. Conclusion Un lien morbide entre ces deux entites — EAD et lupus cutane — est suggere. Le taux normal du complement serique a pu constituer un facteur favorisant au developpement d'une EAD.

Neuromyelitis optica (NMO) is a rare inflammatory and demyelinating disorder of the central nervous system, restricted to optical nerves and spinal cord. The main neuroradiological aspects, now summarized into a complete set of diagnosis criteria, are a normal cerebral MRI at onset and longitudinal involvement of the spinal cord concerning more than 3 vertebral segments. The clinical course and frequency of typical lesions remain unknown.We here report neuroradiological data from patients suffering from NMO.Brain and spinal cord MRI were systematically reviewed for 32 afro-Caribbean patients.A typical longitudinal spinal lesion was seen in 44.7 percent with or without edema; a lesion involving less than 3 vertebral segments in 26.3 percent and no lesion in 21.1 percent. Longitudinal study of a few bouts suggested a progressive normalisation of spinal cord appearance. Atrophy was negatively correlated with immunosuppressive treatment. Cerebral lesions usually absent at onset were correlated to the follow-up. In a non-recursive condition, patients completed diagnostic criteria for encephalic and spinal lesions in 82.8 percent and 48.1 percent.Radiology of spinal bouts showed multiple aspects besides the typical form. The notion of multiple bouts must be added to the spinal criteria to achieve good sensitivity. A typical extensive spinal lesion is usual in the follow-up, but seen after less then half of the bouts. Requiring such a lesion would delay the diagnosis.

Cerebellar ataxia with antiglutamic acid decarboxylase antibodies (GAD-ab) is an exceptional newly recognized autoimmune disorder. The cerebellar ataxia may occur in isolation or be associated with stiff man syndrome another rare GAD-Ab induced disorder of central nervous system.A 38-year-old woman with a past history of Graves disease presented with insidious cerebellar symptoms including ataxic gait, dysmetria, dysarthria, and oscillopsia. A thorough survey of markers of paraneoplastic cerebellar ataxia and collagen diseases was negative. Her serum contained high level of GAD-ab (647.2 U/ml) and MRI evidenced pure cerebellar atrophy leading to diagnosis of autoimmune cerebellar ataxia. Under corticosteroids, cerebellar symptoms partially improved, but serum GAD-ab titre dramatically decreased.Testing for GAD-ab may be indicated in patients with idiopathic cerebellar ataxia, particularly mature women with organ-specific autoimmune diseases. Corticosteroids must be started to prevent irreversible cerebellar atrophy.

To assess the efficacy and safety of lamivudine, an antiviral agent that strongly inhibits hepatitis B virus (HBV) DNA replication, combined with plasma exchanges after short-term corticosteroids for HBV-related polyartertitis nodosa (PAN).Ten patients (8 men, 2 women, mean +/- SD age 50.4 +/- 14.4 years) with previously untreated HBV-related PAN were included in a multicenter, prospective, observational trial. Oral prednisone (1 mg/kg/day) was given for 1 week, then tapered and withdrawn within 1 week. Then, lamivudine (100 mg/day or less in the case of renal insufficiency) was started for a maximum of 6 months. Plasma exchanges were performed simultaneously and scheduled as follows: 3/week for 3 weeks, 2/week for 2 weeks, then 1/week until hepatitis B e antigen (HBeAg) to anti-HBe antibody (HBeAb) seroconversion was obtained or until 2-3 months of clinical recovery was sustained. The primary trial endpoint was clinical recovery from HBV-PAN at 6 months. The secondary endpoint was loss of detectable serum HBeAg and HBV DNA, and HBeAg to HBeAb seroconversion at 9 months.One death, attributed to catheter-related septicemia, was recorded. At 6 months, all 9 survivors had achieved clinical recovery and by 9 months, 6 of 9 (66%) had seroconverted.The strategy of short-term steroids followed by lamivudine and plasma exchanges effectively led to recovery from HBV-PAN. Because of its oral administration and good safety profile, lamivudine should henceforth be considered the antiviral agent of choice to treat HBV-related PAN.

Few data are available regarding stroke among young black patients. We have conducted, in Martinique, a prospective study among young Afro-Caribbeans aged 15 to 45 Years, from June 1994 through May 1999. We identified 60 cerebral infarcts (CI) and 20 cases of intracerebral hemorrhage (ICH). Annual incidence and case fatality rate at 30 days were 7.6/100000/Year (95p.cent confidence interval, 3.13 to 11.35) and 8.3p.cent respectively for CI, and 2.42/100000/Year (95p.cent confidence interval, 0.06 to 4.7) and 25p.cent for ICH. Hypertension was the most prevalent stroke risk factor: 35p.cent in CI and 68p.cent in ICH. According to the TOAST criteria, a probable cause of ischemic stroke was identified in 61.3p.cent. Atherosclerosis, lacunar infarcts and cardioembolism were the main causes of CI (13.3p.cent for each etiology). Spontaneous cervical arterial dissection was found in only 6.7p.cent. Hypertensive ICH (60p.cent) was the most common subtype of ICH. In Martinique, high frequencies of ICH and lacunar infarcts are characteristic of stroke in young Afro-Carribeans. These suggest the role of the high prevalence of hypertension in the black population. We confirm the heterogeneity of stroke etiologies and the low prevalence of cervical arterial dissection in black people.

Concurrent infection with Taenia solium and HIV would be expected to occur more frequently because of the increasing frequency of HIV infection in endemic areas of cysticercosis. However, little is known about the influence of HIV infection on the frequency and the clinical course of cysticercosis. Giant cysts and racemose forms of neurocysticercosis seem to be more frequent in HIV-infected patients and may be secondary to an uncontrolled parasitic growth because of an impaired cell-mediated immune response. We report an unusual case of epidural spinal racemose neurocysticercosis revealed by compression of cauda equina in an HIV-infected man and discuss the potential interactions between T. solium and HIV infections.

Lumbar spine stenosis is a common cause of lower back pain and lower extremity pain especially in people over 60-years-old. Treatment can be surgical or non-surgical. The efficacy of these treatments remains unclear. The purpose of this study was to assess the result of a medical management in a prospective study. Preliminary results are presented.Patients following the clinical and the radiological criteria of inclusion were included in the study. Pain was assessed by visual analogic scale (VAS) and Oswestry scale. Sixty patients meeting inclusion criteria underwent non-surgical intervention including therapeutic exercises and 2 epidural injections. Patients were followed up at 3 and 6 months.The main score on VAS was 5.2 for lumbar pain, 5.8 for radicular pain and 21/50 on the Oswestry scale. Three months later an improvement was noticed in 12 cases. Thirty-seven patients remained unchanged and surgery was decided for 11 patients. At 6 months an improvement was reported by 47% of the patients who have been managed by conservative treatment. No predictive factor except VAS was noticed.Our results are inferior to those previously reported. Most of previous studies are retrospective and criteria of assessment are not based on functional scale as we done. The fact that the treatment management was ambulatory without supervision is probably the main explanation.Conservative treatment for spinal lumbar stenosis remains a reasonable option.

Among candidate genes involved in multiple sclerosis (MS) genetic susceptibility, MHC genes and particularly HLA-DRB1*1501–DQB1*0602 haplotype play a major role. Based on the strong linkage disequilibrium observed in Caucasians between DRB1*1501 and DQB1*0602 alleles, it is still impossible to draw a firm conclusion about the DRB1 or DQB1 locus involvement. In order to address this issue a strategy associating a genetic and a functional approach was conducted in a population of-non-Caucasian MS patients. We observed that in Martinicans (55 MS and 100 controls), the DRB1*15 and DRB1*07 alleles were positively associated with the disease. However in Martinicans the most common DRB1*15 subtype was *1503 and not *1501. Moreover, in Martinicans, the frequency of DQB1*0602, found in association with other DRB1 alleles than DRB1*15 (42% of DQB1*0602 haplotypes), was not increased in DRB1*15-negative MS patients, suggesting a neutral role of DQB1*0602 in MS genetics. In a second step, we demonstrated the capability of the DRB1*1503 allele associated with MS in Martinicans to present the immunodominant autoantigen MBP 85–99 peptide to a DRB1*1501 restricted MBP specific T cell line. Interestingly, structural features of DRB1*1501 or DRB1*1503 molecules are in good fit with the hypothesis that *1501 and *1503 molecules may act similarly in MS development by presenting the same immunodominant MBP peptide. On the whole, our results show a prominent role of the DRB1 locus (DRB1*1501 and/or DRB1*1503 alleles) in the immunodominant MBP 85–99 peptide presentation to genetically different MS patients and suggest a neutral role of the DQB1 encoded molecule in MS susceptibility.

We describe an abnormal chromatin clumping phenomenon (ACC) with nuclear loss of segmentation on circulating neutrophils in three patients receiving mycophenolate mofetil (Cellcept). It is worth being aware of this rare adverse event because of its unknown origin and of its possible clinical consequences.

The optical disease observed concurrent with multiple sclerosis is poorly known in blacks because of the rare occurrence of this pathology in the black population. The few studies currently available suggest more severe problems in black subjects than in Caucasians. Martinique has subjects who are genetically close or even identical but who acquired multiple sclerosis in two very different endemic areas: some in Martinique and others in France.We performed an ophthalmological transversal descriptive study in a population of 57 black multiple sclerosis patients living in Martinique, selected according to the Poser criteria. Patients were divided into two groups: an M group (26 cases) made up of patients who had never left Martinique or the West Indies and an FM group (31 patients) made up of patients who had lived at least one year in France between the ages of 5 and 15.At least one episode of retrobulbar optic neuritis was observed in 16 cases (61.5%) in the M group and in 11 cases (31.5%) in the FM group. The number of eyes with either one episode or more of retrobulbar optic neuritis or papillitis was higher in the M group, 26 cases (50%) than in the FM group, 14 cases (22.6%). Multiple sclerosis began by a disease of the optic nerve in 12 cases (46%) in the M group and in 7 cases (22.6%) in the FM group. The mean visual acuity is 20/30 in the M group and 20/20 in the FM group. The mean value of the p 100 wave was 131 ms in the M group and 113 ms in the FM group.Multiple sclerosis observed in the black population living in Martinique (M group) is characterized by frequent and severe visual problems. The visual phenotype of the FM group is quite similar to the visual phenotype of Caucasians. More than ethnic and genetic factors, the tropical area of acquisition should have an influence on the visual phenotype. For unknown reasons, the optical problems appear severe when multiple sclerosis is acquired in a low endemic area.