Search

Context.— Postmortem evaluation for neurodegenerative disease is expensive in time and materials. These challenges can be met by implementing simpler sampling protocols while preserving anatomic relations. Objective.— To determine the diagnostic effectiveness and cost-effectiveness of a simplified brain blocking protocol compared with the standard blocking protocol used in our Alzheimer's Disease Research Center (ADRC). Design.— We prospectively compared the neuropathologic diagnoses established from our standard 19-cassette/19 brain sites ADRC protocol to a simplified 6-cassette/12 brain sites protocol in 52 consecutive cases. The simplified protocol generated 14 slides for comparison to 52 slides from our standard protocol. Results.— Compared with the ADRC protocol the simplified protocol produced Alzheimer Disease Neuropathologic Changes probability scores that were the same in 50 of 52 cases (r = 0.99). Staging for Lewy pathology was equivalent in 45 of 52 (r = 0.98), scoring for cerebral amyloid angiopathy was equivalent in 48 of 52 (r = 0.97), and grading for arteriolosclerosis was the same in 45 of 52 cases (r = 0.92). Progressive supranuclear palsy (n = 4), multiple system atrophy (n = 2), and corticobasal degeneration (n = 1) could be diagnosed by either protocol independently. The estimated savings per case was 72% or $1744.89 ($2436.37 [ADRC] versus $691.48 [simplified]). Conclusions.— The diagnosis of neurodegenerative disease at autopsy can be done accurately with a less expensive, simplified protocol. Our protocol is similar to those of previously published approaches, but it has a simpler organization scheme. This method should be valuable to institutions where autopsy cost considerations may be important.

PURPOSE Monitoring of physiological parameters is a major concern in Intensive Care Units (ICU) given their role in the assessment of vital organ function. Within this context, one issue is the lack of efficient noncontact techniques for respiratory monitoring. In this paper, we present a novel noncontact solution for real-time respiratory monitoring and function assessment of ICU patients. METHODS The proposed system uses a Time-of-Flight depth sensor to analyze the patient's chest wall morphological changes in order to estimate multiple respiratory function parameters. The automatic detection of the patient's torso is also proposed using a deep neural network model trained on the COCO dataset. The evaluation of the proposed system was performed on a mannequin and on 16 mechanically ventilated patients (a total of 216 recordings) admitted in the ICU of the Brest University Hospital. RESULTS The estimation of respiratory parameters (respiratory rate and tidal volume) showed high correlation with the reference method (r = 0.99; P

Expanding use of immune-checkpoint inhibitors (ICIs) underscores the importance of accurate diagnosis and timely management of neurological immune-related adverse events (irAE-N). We evaluate the real-world frequency, phenotypes, co-occurring immune-related adverse events (irAEs), and long-term outcomes of severe, grade III to V irAE-N at a tertiary care center over 6 years. We analyze how our experience supports published literature and professional society guidelines. We also discuss these data with regard to common clinical scenarios, such as combination therapy, ICI rechallenge and risk of relapse of irAE-N, and corticosteroid taper, which are not specifically addressed by current guidelines and/or have limited data. Recommendations for management and future irAE-N reporting are outlined. ANN NEUROL 2020;87:659-669.

ObjectiveTo describe the spectrum, clinical course, and management of neuropathies associated with immune checkpoint inhibitors (ICIs).MethodsPatients with ICI-related neuropathy (irNeuropathy) were identified and their clinical characteristics compared to neuropathy attributed to cytotoxic agents.ResultsWe identified 19 patients with irNeuropathies. ICIs included anti-programmed death–1 (PD1), 9; anti-cytotoxic T-lymphocyte-associated antigen-4 (CTLA4), 2; and combination of anti-CTLA4 and anti-PD1, 8. Median number of ICI doses prior to neuropathy onset was 4. Rate of neuropathies following ICI therapy was 0.7%. Underlying malignancies included melanoma (n = 15), lung adenocarcinoma (n = 3), and cholangiocarcinoma (n = 1). Neuropathy phenotypes were cranial neuropathies with or without meningitis (n = 7), nonlength-dependent polyradiculoneuropathies with and without cranial nerve involvement (n = 6), small-fiber/autonomic neuropathy (n = 2), ANCA-associated mononeuritis multiplex (n = 1), sensory neuronopathy (n = 1), length-dependent sensorimotor axonal polyneuropathy (n = 1), and neuralgic amyotrophy (n = 1). Immune-related adverse events involving other organ systems were common (58%). Corticosteroid use for management of neuropathy was associated with improvement in median modified Rankin Scale score (1 vs 0, p = 0.001) and Inflammatory Neuropathy Cause and Treatment Disability score (2 vs 0.5, p = 0.012) (Class IV). Significantly higher proportion of irNeuropathies had acute or subacute and nonlength-dependent presentations (p < 0.001) and rate of hospitalization for irNeuropathy was also higher (p = 0.002) compared to toxic neuropathy from chemotherapy.ConclusionNeuropathy is a rare complication of ICIs that often responds to immunosuppression. Recognition of its wide phenotypic spectrum and distinct clinical characteristics and prompt management with corticosteroids may lead to favorable outcomes.

ObjectiveTo develop imaging biomarkers of diseases in the Lewy body spectrum and to validate these markers against postmortem neuropathologic findings.MethodsFour cognitively normal participants with Parkinson disease (PD), 4 with PD with cognitive impairments, and 10 with dementia with Lewy bodies underwent amyloid imaging with [11C]Pittsburgh compound B (PiB) and dopamine transporter (DAT) imaging with [11C]Altropane. All 18 had annual neurologic examinations. All cognitively normal participants with PD developed cognitive impairment before death. Neuropathologic examinations assessed and scored Braak Lewy bodies, Thal distribution of amyloid, Consortium to Establish a Registry for Alzheimer's Disease neuritic amyloid plaques, Braak neurofibrillary tangles, and cerebral amyloid angiopathy, as well as total amyloid plaque burden in the superior frontal, superior parietal, occipital, and inferior temporal cortical regions. PET data were expressed as the standardized uptake value ratio with cerebellar reference. Analyses accounted for the interval between imaging and autopsy.ResultsAll 18 patients met neuropathologic criteria for Lewy body disease; the DAT concentration was low in each case. All patients with elevated [11C]PiB retention measured in a neocortical aggregate had β-amyloid deposits at autopsy. [11C]PiB retention significantly correlated with neuritic plaque burden and with total plaque burden. [11C]PiB retention also significantly correlated with the severity of both Braak stages of neurofibrillary tangle and Lewy body scores. Neuritic plaque burden was significantly associated with neurofibrillary tangle pathology.ConclusionAntemortem [11C]Altropane PET is a sensitive measure of substantia nigra degeneration. [11C]PiB scans accurately reflect cortical amyloid deposits seen at autopsy. These findings support the use of molecular imaging in the evaluation of patients with Lewy body diseases.

Background: Pleomorphic xanthoastrocytomas (PXAs) are uncommon intradural and typically intramedullary astrocytic central nervous system tumors. Although they commonly occur supratentorially, they are rarely seen in the spine. Case Description: A 43-year-old male presented with cervical neck pain and right-sided radicular symptoms. He was found to have an intradural extramedullary mass at the C5–C6 level. The lesion was fully excised and proved to be a PXA. Of interest, the lesion did not recur on postoperative MR imaging studies obtained 7 months later. Conclusion: While rare, primary intradural extramedullary spinal PXA has been reported. Here, we review such a lesion occurring in a 43-year-old male who did well following gross total excision of the tumor.

Background Mycoplasma genitalium (MG) is an emerging pathogen among men who have sex with men (MSM) with raising rates of antibiotic resistance. This study assessed the prevalence and incidence of MG infection in MSM enrolled in the open-label phase of the ANRS IPERGAY trial with on-demand tenofovir disoproxil fumarate/emtricitabine for human immunodeficiency virus prevention and the impact of doxycycline post-exposure prophylaxis (PEP). Methods 210 subjects were tested at baseline and at 6 months by real-time PCR assays for MG detection in urine samples and oropharyngeal and anal swabs. Resistance to azithromycin (AZM), to fluoroquinolones (FQs), and to doxycycline was investigated in the French National Reference Center of Bacterial Sexually Transmitted Infections (STIs). Results The all-site prevalence of MG at baseline was 10.5% (6.3% in urine samples, 4.3% in anal swabs, 0.5% in throat swabs) and remained unchanged at 6 months whether or not PEP was used: 9.9% overall, 10.2% with PEP, 9.6% without. The overall rate of MG resistance (prevalent and incident cases) to AZM and FQs was 67.6% and 9.1%, respectively, with no difference between arms. An in vivo mutation of the MG 16S rRNA, which could be associated with tetracycline resistance, was observed in 12.5% of specimens tested. Conclusions The prevalence of MG infection among MSM on pre-exposure prophylaxis was high and its incidence was not decreased by doxycycline prophylaxis with a similar high rate of AZM and FQ resistance, raising challenging issues for the treatment of this STI and supporting current recommendations to avoid testing or treatment of asymptomatic MG infection.

Group living reduces individual predation risk most effectively when group members are behaviorally and phenotypically similar. Group preferences are influenced by the individual, the members of the shoal, and the environmental conditions. While shoaling behavior has been studied extensively in the threespine stickleback (Gasterosteus aculeatus), it is unclear whether the sex of shoal mates influences the shoal preference of non-reproductive males and females and how this changes under increasing predation risk. Although non-reproductively active sticklebacks are sexually monochromatic in appearance, sex-related differences may result in sexual segregation when shoaling. Here we show that male and female sub-adult threespine sticklebacks had contrasting preferences for shoal mate sex, and that this preference was dependent on the level of predation risk during standardized experimental choice tests. In detail, test fish shoal with the opposite sex within low predation risk trials and with same-sex shoals within high predation risk trials. This difference might be linked to activity patterns; test males were more active than females. Our results demonstrate that differences between the sexes in a species with a sexually monochromatic non-reproductive stage can result in sex-related shoaling preferences. Most studies examining sexual segregation focus on sexually dimorphic species, but these results highlight the potentially widespread occurrence of sexual segregation beyond the sexually dimorphic reproductive stage.

Introduction The small diameter of temporary vascular shunts for vascular trauma management may restrict flow and result in ischemia or early thrombosis. We have previously reported a clinical experience with direct, open surgical reconstruction using expandable polytetrafluoroethylene stent grafts to create a "sutureless" anastomosis as an alternative to standard temporary vascular shunts. We sought to characterize patency and flow characteristics of these grafts compared with standard shunts in a survival model of porcine vascular injury. Methods Twelve Yorkshire-cross swine received a 2-cm-long near-circumferential defect in the bilateral iliac arteries. A 14 Fr Argyle shunt was inserted into one randomly assigned artery, with a self-expanding expandable polytetrafluoroethylene stent deployed in the other. At 72 hours, conduit patency was evaluated by angiography. Arterial flow measurements were obtained at baseline, immediately after intervention, and after 72 hours via direct measurement with perivascular flow meters. Blood pressure proximal and distal to the conduits and arterial samples for histopathology were obtained during the terminal procedure. Results Angiography revealed no difference in patency at 72 hours (p = 1.0). While there was no difference in baseline arterial flow between arteries (p = 0.63), the stent grafts demonstrated significantly improved blood flow compared with shunts both immediately after intervention (390 ± 36 mL/min vs. 265 ± 25 mL/min, p = 0.002) and at 72 hours (261 ± 29 mL/min vs. 170 ± 36 mL/min, p = 0.005). The pressure gradient across the shunts was greater than that of the stent grafts (11.5 mm Hg [interquartile range, 3-19 mm Hg] vs. 3 mm Hg [interquartile range, 3-5 mm Hg], p = 0.013). The speed of deployment was similar between the two devices. Conclusions Open "sutureless" direct site repair using commercially available stent grafts to treat vascular injury is a technically feasible strategy for damage control management of peripheral vascular injury and offers increased blood flow when compared with temporary shunts. Furthermore, stent grafts may offer improved durability to extend the window until definitive vascular repair. The combination of these traits may improve outcomes after vascular injury. Level of evidence Epidemiologic/Prognostic, level III.

A Woman with Weakness, Dark Urine, and Dysphagia A 65-year-old woman was admitted to this hospital because of falls, weakness, dark urine, and difficulty swallowing. Her medical history was notable...

Background CT perfusion (CTP) and diffusion or perfusion MRI might assist patient selection for endovascular thrombectomy. We aimed to establish whether imaging assessments of irreversibly injured ischaemic core and potentially salvageable penumbra volumes were associated with functional outcome and whether they interacted with the treatment effect of endovascular thrombectomy on functional outcome.Methods In this systematic review and meta-analysis, the HERMES collaboration pooled patient-level data from all randomised controlled trials that compared endovascular thrombectomy (predominantly using stent retrievers) with standard medical therapy in patients with anterior circulation ischaemic stroke, published in PubMed from Jan 1,2010, to May 31, 2017. The primary endpoint was functional outcome, assessed by the modified Rankin Scale (mRS) at 90 days after stroke. Ischaemic core was estimated, before treatment with either endovascular thrombectomy or standard medical therapy, by CTP as relative cerebral blood flow less than 30% of normal brain blood flow or by MRI as an apparent diffusion coefficient less than 620 mu m(2)/s. Critically hypoperfused tissue was estimated as the volume of tissue with a CTP time to maximum longer than 6 s. Mismatch volume (ie, the estimated penumbral volume) was calculated as critically hypoperfused tissue volume minus ischaemic core volume. The association of ischaemic core and penumbral volumes with 90-day mRS score was analysed with multivariable logistic regression (functional independence, defined as mRS score 0-2) and ordinal logistic regression (functional improvement by at least one mRS category) in all patients and in a subset of those with more than 50% endovascular reperfusion, adjusted for baseline prognostic variables. The meta-analysis was prospectively designed by the HERMES executive committee, but not registered.Findings We identified seven studies with 1764 patients, all of which were included in the meta-analysis. CTP was available and assessable for 591 (34%) patients and diffusion MRI for 309 (18%) patients. Functional independence was worse in patients who had CTP versus those who had diffusion MRI, after adjustment for ischaemic core volume (odds ratio [OR] 0.47 [95% CI 0.30-0.72], p=0.0007), so the imaging modalities were not pooled. Increasing ischaemic core volume was associated with reduced likelihood of functional independence (CTP OR 0.77 [0.69-0.86] per 10 mL, p(interaction)=0.29; diffusion MRI OR 0.87 [0.81-0.94] per 10 mL, p(interaction)=0.94). Mismatch volume, examined only in the CTP group because of the small numbers of patients who had perfusion MRI, was not associated with either functional independence or functional improvement. In patients with CTP with more than 50% endovascular reperfusion (n=186), age, ischaemic core volume, and imaging-to-reperfusion time were independently associated with functional improvement. Risk of bias between studies was generally low.Interpretation Estimated ischaemic core volume was independently associated with functional independence and functional improvement but did not modify the treatment benefit of endovascular thrombectomy over standard medical therapy for improved functional outcome. Combining ischaemic core volume with age and expected imagingto-reperfusion time will improve assessment of prognosis and might inform endovascular thrombectomy treatment decisions. Copyright (C) 2018 Elsevier Ltd. All rights reserved.

Background: Multiple pregnancy is a high-risk pregnancy associated with a higher maternal and perinatal complications compared to singleton pregnancy. Twinning is the commonest form of multiple pregnancy, and its prevalence varies across the globe, with lowest value in Japan and highest in Nigeria.Methods: The aim of the study was to review twin births in Rivers State University Teaching Hospital (RSUTH), to determine its prevalence, trend, and management outcome.Results: During the period under review, there were 13516, and 263 twin births, giving the prevalence of twinning in RSUTH as 19.5 per 1000 live births or 1 in 51 deliveries. The rate of twinning increased from 7.6 per 1000 deliveries in 2015 to 35.7 per 1000 deliveries in 2019. Mean age of patients was 31 SD 4.82 years, 95% CI: 30.42, 31.59, and modal age group was 30-34 years. Patients’ parity ranged from 0 to 7 with modal parity being para-1. Majority (51.7%) had secondary level education, and were Christians. Preterm delivery rate was 62.4%. The mean gestational age at delivery was 35.7 SD 2.9 weeks, 95% CI: 35.3, 36.0. The mean birth weights of the first and second twins were 2.39 SD 0.67 and 2.30 SD 0.69 respectively. Majority (92%) of the foetuses were alive at birth. Still birth and perinatal mortality rate were 4.2 and 7.8 per 1000 live births. There was no case of maternal mortality.Conclusions: The rate of twining in our setting is high, with an increasing trend. Most of the parturient had preterm delivery, and improved perinatal care services would ensure best perinatal outcome.

Purpose: To evaluate the patient positioning accuracy in radiotherapy using a stereo-time of flight (ToF)-camera system. Methods: A system using two ToF cameras was used to scan the surface of the patients in order to position them daily on the treatment couch. The obtained point clouds were registered to (a) detect translations applied to the table (intrafraction motion) and (b) predict the displacement to be applied in order to place the patient in its reference position (interfraction motion). The measures provided by this system were compared to the effectively applied translations. The authors analyzed 150 fractions including lung, pelvis/prostate, and head and neck cancer patients. Results: The authors obtained small absolute errors for displacement detection: 0.8 ± 0.7, 0.8 ± 0.7, and 0.7 ± 0.6 mm along the vertical, longitudinal, and lateral axes, respectively, and 0.8 ± 0.7 mm for the total norm displacement. Lung cancer patients presented the largest errors with a respective mean of 1.1 ± 0.9, 0.9 ± 0.9, and 0.8 ± 0.7 mm. Conclusions: The proposed stereo-ToF system allows for sufficient accuracy and faster patient repositioning in radiotherapy. Its capability to track the complete patient surface in real time could allow, in the future, not only for an accurate positioning but also a real time tracking of any patient intrafraction motion (translation, involuntary, and breathing).

BACKGROUND Combat-injured patients may require rapid and sustained support during transport; however, the prolonged aortic occlusion produced by conventional resuscitative endovascular balloon occlusion of the aorta (REBOA) may lead to substantial morbidity. Partial REBOA (P-REBOA) may permit longer periods of occlusion by allowing some degree of distal perfusion. However, the ability of this procedure to limit exsanguination is unclear. We evaluated the impact of P-REBOA on immediate survival and ongoing hemorrhage in a highly lethal swine liver injury model. METHODS Fifteen Yorkshire-cross swine were anesthetized, instrumented, splenectomized, and subjected to rapid 10% total blood loss followed by 30% liver amputation. Coagulopathy was created through colloid hemodilution. Randomized swine received no intervention (control), P-REBOA, or complete REBOA (C-REBOA). Central mean arterial pressure (cMAP), carotid blood flow, and blood loss were recorded. Balloons remained inflated in the P-REBOA and C-REBOA groups for 90 minutes followed by graded deflation. The study ended at 180 minutes from onset of hemorrhage or death of the animal. Survival analysis was performed, and data were analyzed using repeated-measures analysis of variance with post hoc pairwise comparisons. RESULTS Mean survival times in the control, P-REBOA, and C-REBOA groups were, 25 ± 21, 86 ± 40, and 163 ± 20 minutes, respectively (p < 0.001). Blood loss was greater in the P-REBOA group than the C-REBOA or control groups, but this difference was not significant (4,722 ± 224, 3,834 ± 319, 3,818 ± 37 mL, respectively, p = 0.10). P-REBOA resulted in maintenance of near-baseline carotid blood flow and cMAP, while C-REBOA generated extreme cMAP and prolonged supraphysiologic carotid blood flow. Both experimental groups experienced profound decreases in cMAP following balloon deflation. CONCLUSION In the setting of severe ongoing hemorrhage, P-REBOA increased survival time beyond the golden hour while maintaining cMAP and carotid flow at physiologic levels.

Chimeric antigen receptor (CAR) T cells have emerged as a promising class of cell-based immunotherapy in refractory malignancies. Neurotoxicity represents a common and potentially life-threatening adverse effect of CAR T cells, and clinical experience is limited. Here, we describe the clinical presentation and management of 25 adult patients who presented with neurotoxic syndromes after CAR T-cell therapy at the Massachusetts General Hospital. This cohort includes 24 patients treated with CD19-directed CAR T cells for non-Hodgkin lymphoma (n = 23) and acute lymphoblastic leukemia (n = 1), and 1 patient treated with α-fetoprotein–directed CAR T cells for hepatocellular carcinoma (n = 1). Twelve of the 25 patients (48%) developed grade 1-2 neurotoxicity and 13 patients (52%) presented with grade 3-4 neurotoxicity. We found that lower platelet counts at time of CAR T-cell infusion were associated with more severe neurotoxicity (P = .030). Cytokine release syndrome occurred in 24 of 25 patients (96%). Serum levels of ferritin peaked with onset of neurologic symptoms, and higher ferritin levels were associated with higher neurotoxicity grade. Grade 3-4 neurotoxicity correlated negatively with overall survival (OS) (P = .013). Median OS of the entire cohort was 54.7 weeks. Eight patients (32%) with grade 3-4 neurotoxicity were deceased at database closure, whereas none died with neurotoxicity grade 1-2. High pretreatment lactate dehydrogenase was frequently encountered in lymphoma patients with grade 3-4 neurotoxicity and correlated negatively with progression-free survival (P = .048). We did not find evidence that steroid use ≥7 days altered the patient’s outcome when compared with

BACKGROUND: General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care.METHODS: For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered.FINDINGS: Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09-2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75-3·10, pINTERPRETATION: Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons.FUNDING: Medtronic.

Background Since 2003, the American Diabetes Association has included pharmacists in the list of diabetes care team members. Indeed, the intervention of clinical pharmacists (CP) has been associated with a decreased risk of medication error (ME) and therefore contributes to the safety of medication management during patients’ healthcare circuit. Purpose The aim of this study was to evaluate the impact of CP activities dispensed by pharmacists in an endocrinology–nutrition unit. Material and methods An observational, prospective, monocentric study was conducted between November 2013 and September 2016 in a nutrition–endocrinology unit (50 beds). 1 senior, 1 junior and 3 student pharmacists were involved in the deployment of clinical pharmacy activities (medication reconciliation at admission and discharge with delivery of drug management plans (DMP), interview of patient (measurement of medication adherence using the Morisky scale (MMAS-4), assessment of drug knowledge (indication, dosage and precautions for use) and risk of hypoglycaemia). All patients who provided verbal consent were entered into a registry with data collected from their hospitalisation, including anthropometric, clinical, therapeutic and biological information (No DC-2009–1052). Results 1655 and 1570 patients received medication reconciliation at admission and discharge, respectively. 596 ME in 407 patients were detected and corrected, most were drug omissions. 597 DMP were explained and delivered to patients. 255 patients received an interview with measurement of medication adherence and assessment of drug knowledge. 64 patients had a low level of adherence, the indication, dosage and precautions for use of medications were known, respectively, in 70%, 80% and 44% of cases. Of the 358 patients interviewed about the risk of hypoglycaemia, respectively, 83 (23%) and 127 (35%) patients reported having had at least one severe hypoglycaemia incident in the year and more than one hypoglycaemia incident by week. Conclusion Deployment of a clinical pharmacy team in the nutrition–endocrinology unit was a complete success. The CP activities allowed safe drug management with the correction of a significant number of ME before they resulted in harm, and highlighted patients requiring therapeutic education. The next step will be to demonstrate that clinical activities dispensed by pharmacist can decrease rehospitalisation of patients with endocrine diseases. No conflict of interest

BACKGROUND Future endovascular hemorrhage control devices will require features that mitigate the adverse effects of vessel occlusion. Permissive regional hypoperfusion (PRH) with variable aortic control (VAC) is a novel strategy to minimize hemorrhage and reduce the ischemic burden of complete aortic occlusion (AO). The objective of this study was to compare PRH with VAC to AO in a lethal model of hemorrhage. METHODS Twenty-five swine underwent cannulation of the supraceliac aorta, with diversion of aortic flow through an automated extracorporeal circuit. After creation of uncontrolled liver hemorrhage, animals were randomized to 90 minutes of treatment: Control (full, unregulated flow; n = 5), AO (no flow; n = 10), and PRH with VAC (dynamic distal flow initiated after 20 minutes of AO; n = 10). In the PRH group, distal flow rates were regulated between 100 and 300 mL/min based on a desired, preset range of proximal mean arterial pressure (MAP). At 90 minutes, damage control surgery, resuscitation, and restoration of full flow ensued. Critical care continued for 4.5 hours or until death. Hemodynamic parameters and markers of ischemia were recorded. RESULTS Study survival was 0%, 50%, and 90% for control, AO, and VAC, respectively (p < 0.01). During intervention, VAC resulted in more physiologic proximal MAP (84 ± 18 mm Hg vs. 105 ± 9 mm Hg, p < 0.01) and higher renal blood flow than AO animals (p = 0.02). During critical care, VAC resulted in higher proximal MAP (73 ± 8 mm Hg vs. 50 ± 6 mm Hg, p < 0.01), carotid and renal blood flow (p < 0.01), lactate clearance (p < 0.01), and urine output (p < 0.01) than AO despite requiring half the volume of crystalloids to maintain proximal MAP ≥50 mm Hg (p < 0.01). CONCLUSION Permissive regional hypoperfusion with variable aortic control minimizes the adverse effects of distal ischemia, optimizes proximal pressure to the brain and heart, and prevents exsanguination in this model of lethal hemorrhage. These findings provide foundational knowledge for the continued development of this novel paradigm and inform next-generation endovascular designs.

Case report A 54-year-old woman with pathological myopia, presented with an elevated, yellowish-white lesion at the inferior border of the myopic conus in her left eye. The optical coherence tomography (OCT) demonstrated an intrachoroidal hyporeflective space. The fluorescein angiography examination (FA) showed early hypofluorescence with delayed staining, with no leakage of contrast. Discussion Recognition of «peripapillary intrachoroidal cavitation» as an own entity associated with pathological myopia is important to avoid confusion with other possible retinal lesions which require further investigation and treatment.

Resumen Caso clinico Mujer de 54 anos, miope magna, que presentaba una lesion sobreelevada y blanco-amarillenta en la parte inferior del conus miopico de su ojo izquierdo. La tomografia de coherencia optica (OCT) mostro un espacio hiporreflectivo intracoroideo. En la angiografia con fluoresceina (AFG) se apreciaba una hipofluorescencia precoz con tincion tardia, sin fuga del contraste. Discusion El reconocimiento de la «excavacion intracoroidea peripapilar» como una entidad propia asociada a la miopia patologica es importante para evitar la confusion con otras posibles lesiones retinianas susceptibles de mas estudios y tratamiento.

BackgroundComplete resuscitative endovascular balloon occlusion of the aorta (C-REBOA) increases proximal mean arterial pressure (MAP) at the cost of distal organ ischemia, limiting the duration of intervention. We hypothesized that partial aortic occlusion (P-REBOA) would maintain a more physiologic proximal MAP and reduce distal tissue ischemia. We investigated the hemodynamic and physiologic effects of P-REBOA vs C-REBOA.Study DesignFifteen swine were anesthetized, instrumented, splenectomized, and subjected to rapid 25% blood volume loss. They were randomized to C-REBOA, P-REBOA, or no intervention (controls). Partial REBOA was created by partially inflating an aortic balloon catheter to generate a 50% blood pressure gradient across the balloon. Hemodynamics were recorded and serum makers of ischemia and inflammation were measured. After 90 minutes of treatment, balloons were deflated to evaluate the immediate effects of reperfusion. End organs were histologically examined.ResultsComplete REBOA produced supraphysiologic increases in proximal MAP after hemorrhage compared with more modest augmentation in the P-REBOA group (p < 0.01), with both groups significantly greater than controls (p < 0.01). Less rebound hypotension after balloon deflation was seen in the P-REBOA compared with C-REBOA groups. Complete REBOA resulted in higher serum lactate than both P-REBOA and controls (p < 0.01). Histology revealed early necrosis and disruption of duodenal mucosa in all C-REBOA animals, but none in P-REBOA animals.ConclusionsIn a porcine hemorrhagic shock model, P-REBOA resulted in more physiologically tolerable hemodynamic and ischemic changes compared with C-REBOA. Additional work is needed to determine whether the benefits associated with P-REBOA can both extend the duration of intervention and increase survival.

Introduction Tumour associated macrophages (TAMs) are an important part of the tumour microenvironment in most cancers. It has been shown that TAMs are mostly anti-inflammatory M2-like macrophages. It is clearly known that M2 macrophages in tumour can inhibit immune responses but the direct effect of these M2 macrophages on cancer cell response to chemotherapeutic drugs is still unknown. Material and methods The aim on this work is to characterise for the first time the direct effect of TAMs on cancer cell chemoresistance. Here, we used THP-1 monocytes firstly differentiated into macrophages (M0) with phorbol 12-mystrate 13-acetate (PMA). Then, M0 macrophages were polarised in M1 or M2 macrophages using LPS and INFg or IL-4 and IL-13 respectively. Using co-cultures with cancer cells, we investigated the effect of these polarised macrophages on the cancer cell resistance to etoposide. Results and discussions The co-culture of macrophages and HepG2 cancer cells reveals that M2 macrophages decreased the etoposide-induced cell death whereas M1 macrophages increased the effects of chemotherapy. These results have been observed by western blot for cleaved Caspase-3 and cleaved PARP-1 and by caspase-3 activity assay in co-culture or by using M2 macrophage conditioned medium. Moreover, a slight chemoresistance was observed in co-culture with unpolarized M0 macrophages. Further investigations revealed that HepG2 cells induced a M0 to M2 polarisation, which seemed to be at the origin of this resistance. The resistance seems to occur by a decrease in DNA damage induction. Furthermore, we showed that M2 conditioned medium increased the expression of cancer stem cell markers by HepG2 cells. Conclusion Taken together, these results show a direct protective effect of M2 macrophages on etoposide induced cell death of HepG2 cancer cells.

Introduction: Clinical decision support (CDS) has been implemented in many clinical settings in order to improve decision-making. Their potential to improve diagnostic accuracy and reduce unnecessary testing is well documented; however, their effectiveness in impacting physician practice in real world implementations has been limited by poor physician adherence. The objective of this systematic review and meta-regression was to establish the effectiveness of CDS tools on adherence and identify which characteristics of CDS tools increase physician use of and adherence. Methods: A systematic review and meta-analysis was conducted. MEDLINE, EMBASE, PsychINFO, the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews were searched from inception to June 2017. Included studies examined CDS in a hospital setting, reported on physician adherence to or use of CDS, utilized a comparative study design, and reported primary data. All tool type was classified based on the Cochrane Effective Practice and Organization of Care (EPOC) classifications. Studies were stratified based on study design (RCT vs. observational). Meta-regression was completed to assess the different effect of characteristics of the tool (e.g. whether the tool was mandatory or voluntary, EPOC classifications). Results: A total of 3,359 candidate articles were identified. Seventy-two met inclusion criteria, of which 46 reported outcomes appropriate for meta-regression (5 RCTs and 41 observational studies). Overall, a trend of increased CDS use was found (pooled RCT OR: 1.36 [95% CI: 0.97-1.89]; pooled observational OR: 2.12 [95% CI: 1.75-2.56]).When type of tool is considered, clinical practice guidelines were superior compared to other interventions (p=.150). Reminders (p=.473) and educational interventions (p=.489) were less successful than other interventions. Multi-modal tools were not more successful that single interventions (p=.810). Lastly, voluntary tools may be supperior to than mandatory tools (p=.148). None of these results are statistically significant. Conclusion: CDS tools accompanied by a planned intervention increases physician utilization and adherence to the tool. Meta-regression found that clinical practice guidelines had the biggest impact on physician adherence although not statistically significant. Further research is required to understand the most effective intervention to maximize physician utilization of CDS tools.

Using a contact delay-line ultrasonic device, we measured the elastic properties particularly the shear modulus μ of pure plutonium and uranium–vanadium alloy from ambient temperature to 900 K. Several allotropes of these materials have been detected in the explored temperature range. For plutonium metal, measurements reveal a collapse of μ ( T ) of about 50% for the α → β phase change and a small increase of 0.2% for the β → γ phase change. For uranium–vanadium alloy, we observe a monotonic decrease of about 50% of μ ( T ) for the α → β phase change. In order to include the phase transition to describe the variation of μ ( T ), a model has been proposed and applied.

This study examined the Personality Assessment Inventory (PAI) in 95 individuals who had suffered a traumatic brain injury (TBI). Participants were recruited from a rehabilitation hospital (n = 60) and a military hospital (n = 35); despite differences in demographics and injury characteristics groups did not differ on any of the clinical scales and were thus combined. In the combined group, the highest mean clinical scale elevations were on Somatic Complaints, Depression, and Borderline Features and the most common configural profiles, based on cluster analysis, were Cluster 1 (no prominent elevations), Cluster 6 (social isolation and confused thinking), and Cluster 2 (depression and withdrawal). Factor analysis indicated a robust three-factor solution that accounted for 74.86 percent of the variance and was similar to findings from the psychiatric and non-psychiatric populations in the standardization sample. The above findings are compared with the previous literature on psychopathology in TBI, particularly in regards to the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), as well as previous psychometric research on the PAI.

The Payne effect is studied in silica-filled polydimethylsiloxane networks, containing various silica loadings and at variable temperature. The effect of a permanent surface treatment of the silica particles, as well as the influence of the incorporation in the system of a processing aid agent, have been investigated. The amplitude of the Payne effect is reduced by introducing a permanent treatment of the silica or a processing aid. Contrary to the unfilled network which shows the typical entropic dependence of the elastic modulus, the low shear strain elastic modulus of filled networks decreases when temperature increases. When the shear strain increases, this temperature dependence becomes less and less pronounced, and reaches a plateau value at deformations above 100%.

The results obtained in Part I, on Polydimethylsiloxane (PDMS) networks filled with treated Aerosil A300 silica at variable temperature and various loadings, have been used to test the quantitative models of the Payne effect proposed by Kraus, Huber-Vilgis, and Maier-Göritz. Each model is able to account only for a part of the experimental results: Kraus and Maier-Vilgis for the variation of the Payne effect with filler volume fraction, Maier-Göritz for the influence of temperature on the Payne effect. But neither of these quantitative models is able to fit the whole set of experimental results on G′ and G″ with a unique set of parameters.

Pour obtenir un panorama actuel de la recherche équine en France et dans le monde, une étude bibliométrique a été réalisée à partir des publications scientifiques concernant le cheval et recensées dans les bases CAB abstracts de CAB International et Current Contents de l’Institute for Scientific Information au cours des années 1998-2000. Après une structuration thématique combinant méthodes bibliométriques et avis d’experts, ces articles ont été ventilés en fonction des thématiques étudiées, des localisations des équipes signataires et du support de communication. Le fichier final comporte 6775 publications, pour deux tiers issues de journaux scientifiques, 31 % provenant de journaux de transfert et 6 % de comptes rendus de congrès. Plus de la moitié des contributions traitent de pathologie. Viennent ensuite la locomotion et médecine sportive (17 %), la reproduction (11 %). La nutrition et la génétique se partagent 9 % des contributions. Les autres thématiques définies en sciences du vivant sont le comportement et bien-être, les espèces asines et les équidés sauvages, le dopage. Environ 4 % des notices relèvent des sciences humaines et sociales. L’Amérique du Nord et l’Union Européenne constituent les deux principaux pôles de recherche mondiaux avec 40 et 36 % des articles chacun. La France occupe la 7ème place (3,4 % des articles scientifiques) derrière les USA, le Royaume-Uni (12,5 %), l’Allemagne (6,3 %), le Japon (4,3 %), le Canada (3,8 %) et l’Australie (3,8 %). La France remonte à la 4ème place si l’on si l’on considère l’ensemble des articles. Ceci illustre l’importance de la littérature de transfert ou de comptes rendus de colloques. La France apparaît relativement spécialisée sur la reproduction, le dopage et les sciences humaines et sociales, avec en revanche un investissement relatif moindre sur le comportement et la pathologie. La région Ile de France est la première région française en matière de recherche équine, avec 37,5 % des articles. Les autres régions importantes sont les régions Centre, Rhône-Alpes, Pays de la Loire, Midi-Pyrénées et Basse-Normandie. Cette atomisation géographique des équipes explique qu’aucune ville française ne figure parmi les 25 villes leaders.

This article describes the postinjury cognitive functioning of a sample of active duty, retired, and military beneficiaries who received traumatic brain injuries. Patients were seen in the neuropsychology clinic at Brooke Army Medical Center for a detailed cognitive and personality assessment. The scores on a major component of this evaluation, the Wechsler Adult Intelligence Scale, third edition, are summarized. The results are compared with those reported in the Wechsler Adult Intelligence Scale, third edition technical manual for a smaller, less diverse sample. The findings are consistent with the formulation that stable verbal skills are most resistant to brain injury, followed by nonverbal reasoning and visuospatial ability, and then working memory with speed of information processing being the most vulnerable to the effects of brain injury.

This study investigates the extent to which working memory, motor speed and perceptual processing speed influence Wechsler Adult Intelligence Scale-III (WAIS-III) Processing Speed Index (PSI) scores. Sixty-eight adult outpatients with Traumatic Brain Injury (TBI) of varying severity and complete data on all outcome measures were identified. Two cases with outlying values on one outcome measure were omitted from the final sample. Working memory was measured by the Working Memory Index score from the WAIS-III. Motor speed was measured as score on the Halstead-Reitan Finger Oscillation Test (finger tapping) and perceptual processing as score on the Trail Making Test--Part B. In hierarchical multiple regression analyses, working memory accounted for 10% of the variance in PSI scores, whereas motor speed only accounted for 3%. An independent measure of perceptual processing, Trail Making Test--B, accounted for 26% of the variance in WAIS-III PSI scores. The total variance accounted for by the three factors was 56%. Findings confirm that the WAIS-III PSI scores of individuals who have received a TBI reflect perceptual processing speed, with an additional component attributable to working memory. Motor speed made only a small contribution to WAIS-III PSI scores in the present sample.

Understanding the way fillers can reinforce elastomers requires, among other things, requires a precise description of the behavior of filler aggregates when a macroscopic strain is applied. In this study, Atomic Force Microscopy was used to investigate samples of SBR and PDMS filled with silica. The samples were stretched uniaxially at different strain values (up to 145%) and imaged by Atomic Force Microscopy. The distances between aggregates were followed at the different strains, which allowed calculation of the local strains and comparison of the values obtained with the macroscopic strain value. The main results are (i) that the strain field is highly heterogeneous, depending on the local concentration of filler and (ii) that the strain undergone by elastomer chains can be very high locally, in the regions where distances between aggregates are very short.

As the reality of climate change becomes accepted in the scientific community, it is critical to continue to understand its impact on the ground, particularly for communities dependent on agriculture and natural resources. To do so, the analysis of vulnerability – in other words, the capacity of communities to cope with the effects of change – is critical. An extension of this is the analysis of social structures, and how they shape patterns of vulnerability and the capacity for individuals or groups to adapt. This review presents a framework for understanding structural vulnerability to climate change in the Ganges River Basin countries–Nepal, India and Bangladesh – with a focus on the role of gender in shaping vulnerability. This paper reviews the extensive academic and ‘gray’ literature from the region to identify a set of key economic and social inequalities which shape how men and women are differently affected by climate change and their capacity to adapt. The impact of climate change in the Ganges River Basin is complex. With regard to agriculture, the most notable stress is the increased unpredictability of weather patterns. This includes extreme weather events such as droughts, floods and cyclones, not to mention more subtle changes related to the onset of the monsoon and the frequency of rainfall. An increase in temperature extremes is also a notable concern, affecting both winter and summer cropping. The impact has locally specific manifestations according to the geography. For example, falling water tables exacerbated by droughts is a concern in some parts of the Gangetic Plains; extreme events such as flooding or cyclones can lead to an increase in saline intrusion in the Ganges Delta, while they can cause more frequent landslides or other mass movements in the Himalayas. With regard to ‘vulnerability’ in the context of climatic stress, this paper takes a broadly social constructivist approach. In other words, vulnerability is not considered as a consequence of natural hazards alone. Instead, it is related to one’s resilience and capacity to cope with, or adapt to, the context of natural hazards, a process which is intricately connected to social structures such as gender, class, caste and ethnicity. A first form of ‘gendered’ vulnerability to climate change relates to labor. In a region with highly inequitable gender division of labor, the workload of women can be increased by climate change. Women often play an important role in natural resource-based livelihood activities which fall within the sphere of reproduction such as the collection of fuelwood and water. Ecological changes such as salinity intrusion or changes in groundwater availability can force women to travel longer distances. There is often a class dimension, whereby women from wealthier households have their own resources such as tube wells in their homesteads, and thus their burden is less. A second reason why the gender division of labor is important for vulnerability is that women and men often have separate control over different income sources. If climate change undermines a particular livelihood activity, this may differentially impact men’s or women’s individual incomes. This impacts women in South Asia in particular, as the personal income they can control is often more limited than that of men. Gender norms which restrict their involvement in the public sphere in activities such as labor and trade mean that agriculture and natural resource-based livelihood activities often represent the primary sources of personal cash income. These activities are highly vulnerable to climate change. Gendered vulnerability can also emerge from more complex processes such as male out- migration, which is often a primary response to climate stress on agriculture for the most marginal cultivators. While the seasonal or permanent migration of male household members can increase women’s control over income and household affairs, it can also increase their vulnerability to shocks. For example, women-headed households that have increased following male out-migration are viii particularly vulnerable to natural disasters such as floods, with the loss of family support networks. Similarly, their workload is often increased as they have to take on responsibilities of former male labor on the farm, particularly in poorer households that cannot afford to hire outside laborers. Climate change not only puts women under increased economic stress, but can also affect their welfare in other more complex ways. For example, women are more likely than their male counterparts to suffer in the period following natural disasters when, often, a larger number of females than males face fatalities. This can occur for multiple reasons including the fact that women often leave the homestead last, have less access to information and warnings, or face restrictions on entering public storm shelters. Similarly, during food crises which follow natural disasters, women often forgo an adequate diet to ensure that children and other family members remain well fed. The economic stress brought about by climate change and associated natural disasters has also been shown to increase cases of violence against women. This includes an increase in the trafficking of girls, as well as an increase in violence and harassment of women brought about by increased competition for resources both within the household, and between households. Another set of questions this review addresses relates to the capacity for households and individuals to adapt to climate change. In particular, women’s capacity to adapt to climate stress has been shown to be more limited than men’s, for multiple complex reasons. In South Asia, women face numerous legal and cultural barriers in owning or inheriting property. The tendency for land to be registered in the male name restricts women’s bargaining power in the sale of the produce of their land, and women-owned holdings are often too small for many productivity- enhancing or climate-smart technologies. Lack of land also restricts women’s access to agricultural services (for which landownership papers are required), and renders them more dependent upon common-property-resource-dependent activities, such as livestock-rearing, which are often highly vulnerable to climate stress. A related challenge for women’s adaptation to climate change is accessing finance, lower levels of education, and more restricted social networks and access to markets, all of which restrict their capacity to diversify into new livelihood activities. There are numerous state programs aimed at facilitating climate change adaptation at a local level including those oriented at disaster preparedness and improving the resilience of agriculture. However, the capacity of women to benefit from state resources or to contribute to local-level decision making is often limited. Even in the context of equal rights on paper, women often face discrimination due to entrenched cultural norms when policies are implemented. At the same time, national-level policies and practices often fail to account for the needs of women or value women’s agroecological knowledge. Policy interventions to facilitate equitable climate change adaptation for both men and women include ensuring women’s rights to land, making more effective use of microfinance through a more integrated approach. Other proposals include the promotion of collective action and cooperative structures amongst women, and the integration of indigenous knowledge into programs for adaptation to climate change. Underlying this is a need for bottom-up climate change adaptation planning, which understands local needs and knowledge, including those of both men and women. Programs and policies for adaptation of climate change will also be more effective if the roles of local institutions which provide incentives for collective action are better understood. It is also clear that gendered vulnerability to climate change intersects class inequalities. Addressing structural poverty at a much broader level clearly emerges as being a central condition for successful adaptation and mitigation, particularly given that women from poorer households are the most vulnerable to climate change. There is also a need for strong enabling policies and institutional mechanisms that embed a commitment to tackle gender equality across society. Legal and societal commitments to gender equality are essential so that poor women, their families and their communities are given the capacity to adapt to the adverse impact of climate change.

Silica-filled polydimethylsiloxane networks are submitted to successive stretching cycles, in order to get the stabilized stretching curve, at variable temperature. This study explains the peculiar temperature dependence of the first stretching curve of filled rubbers, and highlights the molecular origin of the stress-softening phenomenon, known as Mullins effect. Thanks to the comparison between the strain dependence of stress and the molecular orientation, this effect is attributed to the detachment from the filler surface or slippage on the filler surface, of chains having reached their limit of extensibility. Moreover, by taking advantage of Atomic Force Microscopy observations on stretched samples, the Mullins effect is shown to take place mainly in regions of high local concentration of silica. The experimental results are also compared to Bueche's model for the Mullins effect.

Tapping mode atomic force microscopy experiments were conducted on silica-filled silicone elastomers. Phase images provide a good contrast between the silicone matrix and silica structures, and allow the study of silica microdispersions. However, the phase contrast is sensitive to several experimental factors, which affect the magnitude of tip-sample interactions. The dependence of the phase contrast on the free amplitude of cantilever oscillation, on the setpoint ratio, on the cantilever stiffness and on the sample modulus was investigated. The setpoint ratio was shown to be the main parameter controlling the tip-sample force, and consequently the phase contrast. By comparing the results with transmission electron microscopy experiments, the tapping mode atomic force microscopy with phase imaging is established as an easy and powerful technique for the characterization of the silica dispersion in a silicone matrix. This study opens the way for using Atomic force microscopy to get a better understanding of reinforcement in filled rubbers.

Inhaled ultrafine particles are increasingly being recognized as a potential threat to health. Aerosols in workplace environments may come from a wide variety of sources, depending on the type of activity and processes taking place. Some activities and processes are acknowledged as being ‘dusty’, where aerosol is generated from the mechanical handling and attrition of solid or liquid material, and are not considered to be plausible sources of ultrafine particles. However, hot processes, involving the vaporization of material, and inevitable subsequent cooling, do have the potential to generate significant number concentrations of ultrafine particles. However, consideration of the physical conditions required for the generation of particles in the range below 100 nm suggests that those conditions are not easily met in workplaces. More generally, the conditions are such that particles grow out of this range, either by continuing condensation (as happens at high vapour concentrations) or by agglomeration between smaller particles (as happens at high number concentrations). Not much is known about ultrafine particles in actual workplaces, mainly because our view has been obscured for the past few decades by the fact that most occupational aerosol standards have been based on the mass concentration of airborne particulate matter. Now that a new awareness has set in, it is expected that new research will address the problem. Most current aerosol standards are expressed in terms of the mass concentration of particulate matter conforming to a particle size fraction, where the latter is based on knowledge of how particle size relates to where particles deposit in the human respiratory tract and any subsequent effects. At present no such basis exists for ultrafine particles, but one is needed before progress can be achieved towards meaningful standards for occupational ultrafine aerosols. It is expected that, for ultrafine particles, such a standard may, in the future, be expressed in terms of the number concentration of particles less than a certain size, that size to be determined on the basis of the physical and chemical nature of the particle at that size, human physiology and toxicology.

Heat stroke includes neurologic impairment as a person's body temperature reaches 40.5 degrees C (105 degrees F) as a result of a failure of thermoregulation. The physiologic complications of heat stroke are well described in the literature. The domains of cognitive functioning affected and the severity of impairment resulting from heat stroke can vary from mild deficits in attention and memory to severe global dementia. There can also be changes in affect and personality that are equally debilitating. This article presents the neuropsychological test results of three active duty soldiers who suffered heat stroke and were tested within 2.5 months of injury.