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BACKGROUND: Emergency medical services (EMS) personnel have already made substantial contributions to improving care for patients with time-dependent illnesses, such as trauma and myocardial infarction. Patients with sepsis could also benefit from timely prehospital care.METHODS: After training EMS personnel in recognising sepsis, we did a randomised controlled open-label trial in ten large regional ambulance services serving 34 secondary and tertiary care hospitals in the Netherlands. We compared the effects of early administration of antibiotics in the ambulance with usual care. Eligible patients were randomly assigned (1:1) using block-randomisation with blocks of size 4 to the intervention (open-label intravenous ceftriaxone 2000 mg in addition to usual care) or usual care (fluid resuscitation and supplementary oxygen). Randomisation was stratified per region. The primary outcome was all-cause mortality at 28 days and analysis was by intention to treat. To assess the effect of training, we determined the average time to antibiotics (TTA) in the emergency department and recognition of sepsis by EMS personnel before and after training. The trial is registered at ClinicalTrials.gov, number NCT01988428.FINDINGS: 2698 patients were enrolled between June 30, 2014, and June 26, 2016. 2672 patients were included in the intention-to-treat analysis: 1535 in the intervention group and 1137 in the usual care group. The intervention group received antibiotics a median of 26 min (IQR 19-34) before arriving at the emergency department. In the usual care group, median TTA after arriving at the emergency department was 70 min (IQR 36-128), compared with 93 min (IQR 39-140) before EMS personnel training (p=0·142). At day 28, 120 (8%) patients had died in the intervention group and 93 (8%) had died in the usual care group (relative risk 0·95, 95% CI 0·74-1·24). 102 (7%) patients in the intervention group and 119 (10%) in the usual care group were re-admitted to hospital within 28 days (p=0·0004). Seven mild allergic reactions occurred, none of which could be attributed to ceftriaxone.INTERPRETATION: In patients with varying severity of sepsis, EMS personnel training improved early recognition and care in the whole acute care chain. However, giving antibiotics in the ambulance did not lead to improved survival, regardless of illness severity.FUNDING: The NutsOhra Foundation, Netherlands Society of Internal Medicine (NIV).

We report a case of bilateral lacrimal gland involvement as the first sign of Waldenstrom's macroglobulinaemia in a patient with sarcoidosis. Histological analysis of an incisional biopsy revealed a lymphoplasmocytic lymphoma consistent with Waldenstrom's macroglobulinaemia. No noncaseating granulomas were encountered. Systemic treatment was initiated and resulted in complete resolution of the lesions. In a patient with a systemic disease, such as sarcoidosis, and lacrimal gland involvement, a biopsy of the lacrimal gland mass should be taken to make a correct diagnosis and start appropriate treatment.

1.1. The action of visual stimuli and of mental work on the paroxysm of 3/sec spike and wave complexes produced by flicker in a case of centrencephalic epilepsy has been studied. 2.2. Opening of the eyes during 3–5 sec, or shining a bright light on the eyelids, prior to the application of flicker, exerts a long-term dynamogenic action on the paroxysms. The discharge is reduced, as is well known, when the eyes are open during flicker, presumably through the operation of a neuronal desynchronisation phenomenon. 3.3. Mental calculation leads to a prolonged depression of the mechanism responsible for the paroxysms, which seems to result from true inhibitory processes. 4.4. The results suggest that an enhancement of the level of vigilance can depress the centrencephalic epileptic discharges set up by flicker, as a result of thalamo-cortical activation-desynchronisation processes as well as true centrencephalic inhibition.

Experimental allergic encephalomyelitis (EAE) is a useful animal model for the study of immune-mediated demyelination. It has been clearly established that the induction of EAE is dependent on cell-mediated immune reactions requiring T-cell sensitization to myelin basic protein, although the possibility that an antibody (B-cell) response may have an important pathogenic role cannot be ruled out1–3. The histopathology of the ordinary, acute form of the disease is characterized by perivascular infiltrates of haematogenous mononuclear cells4. Demyelination is observed in the vicinity of the invading mononuclear cells, but its precise mechanism is still the subject of much speculation. Recent studies support the view that macrophages, activated within the central nervous system (CNS) by mediators released by sensitized T lymphocytes interacting with the appropriate antigen, secrete myelinolytic products including proteinases5–7.

De nombreux auteurs estiment, sur la base de ressemblances électroencéphalo graphiques observées au sein d'une même famille ou chez des paires de jumeaux MZ, que l'EEG est déterminé génétiquement (Lennox et al, 1945; Weiss et Rudkowka, 1962; Vogel, 1965; Heuschert, 1965). Beaussart et al (1959) pensent même que cet examen peut servir de critère pour le diagnostic de monozygotie.Nous avons tenté de vérifier si l'étude de la maturation de l'EEG conduisait aux même conclusions. Nous avons comparé le degré de maturation de l'électrogenèse corticale che: des paires de jumeaux concordants et discordants pour les groupes ABO, MN et Rh. Nous nous sommes adressés à des enfants et des adolescents. On sait que, chez ceux-ci, l'EEG comporte, en plus du rythme α, des ondes θ dont les fréquences sont de 4-7/sec, et des ondes δ de fréquences inférieures à 4/sec. Ces ondes lentes diminuent progressivement avec l'âge poui disparaître chez l'adulte normal. À un âge donné, leur nombre est très variable d'un suje à l'autre. Le degré de maturation de l'EEG peut donc être apprécié de façon simple par l'évaluation de la proportion d'ondes lentes du tracé.Notre étude a porté, d'une part, sur 24 paires de jumeaux concordants sanguins, âgés en moyenne, de 10.5 ans (6-18 ans) et, d'autre part, sur 34 paires de jumeaux discordants âgés, en moyenne, de 9.3 ans (6-16 ans). Les sujets étaient d'origine rurale et appartenaien à un même groupe socio-économique. Le quotient intellectuel moyen était de 92.8 pour les concordants et de 93.5 pour les discordants.