A decision-making algorithm for remote digital assessments of Alzheimer's Disease

INTRODUCTION

Remote digital assessments (RDA) such as voice recording, video and motor sensors, olfactory, hearing and vision screenings are now starting to be employed to complement classical biomarker and clinical evidence to identify patients in the early AD stages. Choosing which RDA can be proposed to individual patients is not trivial, and often time consuming. This position paper presents a decision-making algorithm for using RDA during teleconsultations in memory clinic settings.

METHOD

The algorithm was developed by an expert panel following the Delphi methodology.

RESULTS

The decision-making algorithm is structured as a series of yes-no questions. The resulting questionnaire is freely available online.

DISCUSSION

We suggest that the use of screening questionnaires in the context of Memory clinics may help accelerating the adoption of remote digital assessment in everyday clinical practice.

The first quick olfactory test specific for Alzheimer's disease and French culture

PURPOSE

Olfactory identification disorder is considered a promising early biomarker of Alzheimer's disease (AD). The QUICK TODA2 can be used as a short olfactory screening tool specific for French AD patients. The selection of AD specific odorants and the design of this screening were the main objectives of this twofold study.

METHODS

In study 1, the TODA2 olfactory test was administered to 43 mild-AD patients and 45 healthy controls (HC) in five memory centres in France. The selection of AD specific odorants was based on the differences in the proportion of correct answers and in the threshold means between AD and HC groups. In study 2, another set of 19 mild-AD patient were included at the memory centre of Nice Hospital. All participants completed the olfactory assessment pipeline including the QUICK TODA2, TODA2 and Sniffin' Sticks Identification sub-Test (SST-i). The individual scores of the three tests were correlated.

RESULTS

In study 1, ten TODA2 odorants could significantly differentiate AD participants from controls. We selected the six most AD-sensitive items to design the QUICK TODA2. In study 2, we reported strong significant correlations between QUICK TODA2 and TODA2 (ρ(17) = 0.68, p = 0.001**), SST-i and QUICK TODA2 (ρ(17) = 0.65, p = 0.002**), SST-i and TODA2 (ρ(17) = 0.57, p = 0.01*).

CONCLUSION

 QUICK TODA2 is a 5-min non-invasive olfactory AD screening tool dedicated to French culture. Its results converge with those of longer, validated olfactory tests. It could be used as a quick screening tool in the general daily practice before an extensive assessment in memory centres.

Productive art engagement in a hybrid format: effects on emotions of older adults during COVID-19 pandemic

Introduction

Previous studies have shown benefits of productive art-activity on frail older adults' mental and physical health. In this study, we investigated the effects of art-producing activities in a hybrid format (in-person and online) in a context of lockdown compared with previous studies taking place in museums and their effects on wellbeing, quality of life, physical frailty, and apathy in older adults.

Methods

We conducted a randomized unicentric control trial on a sample of 126 seniors older than 65 years (mean age 71.9 ± 2.3, 81% women) living in Nice (France). Participants were randomized in two parallel groups (intervention group with n = 62 vs. control group with n = 64) conducted during pandemic, between March and May 2021. The intervention group involved participatory art-based activities conducted in a hybrid format, either in-person or online, once a week for 2 h over a 12-week period. No specific intervention was proposed to the control group. The main aim was to evaluate how this hybrid format would impact the wellbeing, quality of life, and physical frailty of participants. The secondary aim was to compare our results with the previous studies conducted by Beauchet et al., and the third aim was to evaluate the impact of the intervention on apathy. Validated scales were implemented in RedCap and administered at baseline (M0) and at the end of the third month (M3).

Results

The intervention group showed significant improvement in their quality of life (p = 0.017) and their level of apathy (p = 0.016) after intervention. Emotional blunting increased significantly in the control group (p = 0.016) while it remained stable in the intervention group. No significant improvement was observed on the frailty, and wellbeing scores remained constant in both groups.

Conclusion

This randomized control trial confirmed emotional effects on seniors practicing an art-based activity in a hybrid format during pandemic on a weekly basis for 3 months.

Clinical Trial Registration

ClinicalTrials.gov, identifier: NCT04570813.

Teleconsultations for mental health: Recommendations from a Delphi panel

Introduction

The use of teleconsultations for mental health has drastically increased since 2020 due to the Covid19 pandemic. In the present paper, we aimed to analyze the advantages and disadvantages of teleconsultations for mental health compared to face-to-face consultations, and to provide recommendations in this domain.

Methods

The recommendations were gathered using a Delphi methodology. The expert panel (N = 21) included professionals from the health and ICT domains. They answered questions via two rounds of web surveys, and then discussed the results in a plenary meeting. Some of the questions were also shared with non-experts (N = 104).

Results

Both the experts and the non-experts with teleconsultation experience reported a general satisfaction concerning teleconsultations. A SWOT analysis revealed several strengths and opportunities of teleconsultations for mental health, but also several weaknesses and threats. The experts provided a set of practical recommendations for the preparation and organization of teleconsultations for mental health.

Discussion

Teleconsultations for mental health have the potential to allow access to care for patients in remote and isolated areas. Thus, their use will unlikely be discontinued after the end of the pandemic. In this context, we suggest that the collaboration among clinicians, researchers, and interface designers is crucial to improve usability and user experience for both clinicians and patients. The importance of teaching teleconsultation skills and informing the public on the features of teleconsultations (e.g., data privacy/security) is also highlighted.

Development of ELIP to Assess Physical Literacy for Emerging Adults: A Methodological and Epistemological Challenge

Purpose: Following increased interest in physical literacy (PL), development of appropriate tools for assessment has become an important next step for its operationalization. To forward the development of such tools, the objective of this study was to build the foundations of the Évaluation de la Littératie Physique (ELIP), designed to help reduce existing tensions in approaches to PL assessment that may be resulting in a low uptake into applied settings. Methods: We followed two steps: (1) the development of the first version of ELIP by deploying a Delphi method (n = 30); and (2) the modification of items through cognitive interviews with emerging adults (n = 32). Results: The expert consensus highlighted four dimensions of PL to be assessed-physical; affective; cognitive; and social-with new perspectives, including a preference for broad motor tests over fitness. Conclusion: Results offer new insights into the assessment of emerging adults' PL, but ELIP still requires further work concerning validity, reliability, and sensitivity.

[Mindfulness meditation and art therapy for Alzheimer's patients and their caregivers]

Alzheimer's disease affects nearly three million people in France, and requires training for both healthcare professionals and caregivers. Our study underlines the value of supporting an adapted program based on mindfulness meditation, to reduce anxiety and stress for patients and their caregivers.

The course of primary progressive aphasia diagnosis: a cross-sectional study

Background

The primary progressive aphasia (PPA) diagnosis trajectory is debated, as several changes in diagnosis occur during PPA course, due to phenotype evolution from isolated language alterations to global cognitive impairment.

The goal of the present study, based on a French cohort, was to describe the demographics and the evolution of subjects with (PPA) in comparison with Alzheimer’s disease (AD) on a period of 7 years.

Methods

We conducted a repeated cross-sectional study. The study population comprised individuals with PPA and AD diagnosis (N=167,191) from 2010 to 2016 in the French National data Bank (BNA). Demographic variables, MMSE scores, diagnosis status at each visit and prescribed treatments were considered.

Results

From 2010 to 2016, 5186 patients were initially diagnosed with PPA, 162,005 with AD. Compared to AD subjects, significant differences were found concerning age (younger at first diagnosis for PPA), gender (more balanced in PPA), education level (higher in PPA) and MMSE score (higher of 1 point in PPA).

Percentage of pending diagnosis, delay between first consultation and first diagnosis and the number of different diagnoses before the diagnosis of interest were significantly higher in PPA group compared to AD group. Pharmacological and non-pharmacological treatments were significatively more recommended following PPA than AD diagnosis.

Conclusion

This study improves the knowledge of PPA epidemiology and has the potential to help adopting appropriate public health service policies. It supports the hypothesis that PPA is diagnosed later than AD. The PPA diagnosis increases the prescription of non-pharmacological treatments, especially speech and language therapy (SLT) that is the main treatment available and most effective when at the initial stage.

Trial registration

ClinicalTrials.gov identifier NCT03687112

Supplementary Information

The online version contains supplementary material available at 10.1186/s13195-022-01007-6.

[Physical activity and chronic diseases : how can motivational principles contribute to physically active behaviour ?]

Although physical activity is perceived as an effective therapeutic agent in the management of chronic diseases, the literature reports a low participation rate in adapted physical activity programmes and a high drop-out rate during participation. There is room for improvement in supporting the engagement of chronically ill patients in an active lifestyle, especially in optimising the process from medical management to integration into a local adapted sports structure. Based on the motivational principles of the self-determination theory, we propose courses of action to optimise the support of the chronically ill patient in the process of behavioural change. This article emphasises the importance of placing the individual at the centre of his or her physical care and the importance of taking into account individual characteristics in order to act on intrinsic motivation.

Primary Progressive Aphasia: Use of Graphical Markers for an Early and Differential Diagnosis

Primary progressive aphasia (PPA) brings together neurodegenerative pathologies whose main characteristic is to start with a progressive language disorder. PPA diagnosis is often delayed in non-specialised clinical settings. With the technologies' development, new writing parameters can be extracted, such as the writing pressure on a touch pad. Despite some studies having highlighted differences between patients with typical Alzheimer's disease (AD) and healthy controls, writing parameters in PPAs are understudied. The objective was to verify if the writing pressure in different linguistic and non-linguistic tasks can differentiate patients with PPA from patients with AD and healthy subjects. Patients with PPA (n = 32), patients with AD (n = 22) and healthy controls (n = 26) were included in this study. They performed a set of handwriting tasks on an iPad® digital tablet, including linguistic, cognitive non-linguistic, and non-cognitive non-linguistic tasks. Average and maximum writing pressures were extracted for each task. We found significant differences in writing pressure, between healthy controls and patients with PPA, and between patients with PPA and AD. However, the classification of performances was dependent on the nature of the tasks. These results suggest that measuring writing pressure in graphical tasks may improve the early diagnosis of PPA, and the differential diagnosis between PPA and AD.

Grasping Social Apathy: The Role of Reach-To-Grasp Action Kinematics for the Assessment of Social Apathy in Mild Neurocognitive Disorders

BACKGROUND

Social apathy, a reduction in initiative in proposing or engaging in social activities or interactions, is common in mild neurocognitive disorders (MND). Current apathy assessment relies on self-reports or clinical scales, but growing attention is devoted to defining more objective, measurable and non-invasive apathy proxies.

OBJECTIVE

In the present study we investigated the interest of recording action kinematics in a social reach-to-grasp task for the assessment of social apathy.

METHODS

Thirty participants took part in the study: 11 healthy controls (HC; 6 females, mean age = 68.3±10.5 years) and 19 subjects with MND (13 females, mean age = 75.7±6.3 years). Based on the Diagnostic Criteria for Apathy, MND subjects were classified as socially apathetic (A-MND, N = 9) versus non-apathetic (NA-MND, N = 10). SensRing, a ring-shaped wearable sensor, was placed on their index finger, and subjects were asked to reach and grasp a can to place it into a cup (individual condition) and pass it to a partner (social condition).

RESULTS

In the reach-to-grasp phase of the action, HC and NA-MND showed different acceleration and velocity profiles in the social versus individual condition. No differences were found for A-MND.

CONCLUSION

Previous studies showed the interest of recording patients' level of weekly motor activity for apathy assessment. Here we showed that a 10-min reach-to-grasp task may provide information to differentiate socially apathetic and non-apathetic subjects with MND, thus providing a tool easily usable in the clinical practice. Future studies with a bigger sample are needed to better characterize these findings.

How many patients are eligible for disease-modifying treatment in Alzheimer's disease? A French national observational study over 5 years

OBJECTIVE

We aimed to study the epidemiology of the prodromal and mild stages of Alzheimer's disease (AD) patients who are eligible for clinical trials with disease-modifying therapies.

SETTINGS

We analysed two large complementary databases to study the incidence and characteristics of this population on a nationwide scope in France from 2014 to 2018. The National Alzheimer Database contains data from 357 memory centres and 90 private neurologists. Data from 2014 to 2018 have been analysed.

PARTICIPANTS

Patients, 50-85 years old, diagnosed with AD who had an Mini-Mental State Exam (MMSE) score of ≥20 were included. We excluded patients with mixed and non-AD neurocognitive disorders.

PRIMARY OUTCOME MEASURE

Descriptive statistics of the population of interest was the primary measure.

RESULTS

In the National Alzheimer Database, 550 198 patients were assessed. Among them, 72 174 (13.1%) were diagnosed with AD and had an MMSE ≥20. Using corrections for specificity of clinical diagnosis of AD, we estimated that about 50 000 (9.1%) had a prodromal or mild AD. In the combined electronic clinical records database of 11 French expert memory centres, a diagnosis of prodromal or mild AD, certified by the use of cerebrospinal fluid AD biomarkers, could be established in 195 (1.3%) out of 14 596 patients.

CONCLUSIONS

AD was not frequently diagnosed at a prodromal or mild dementia stage in France in 2014 to 2018. Diagnosis rarely relied on a pathophysiological marker even in expert memory centres. National databases will be valuable to monitor early stage AD diagnosis efficacy in memory centres when a disease-modifying treatment becomes available.

Sex ratio in dementia with Lewy bodies balanced between Alzheimer's disease and Parkinson's disease dementia: a cross-sectional study

Background

Gender distribution varies across neurodegenerative disorders, with, traditionally, a higher female frequency reported in Alzheimer’s disease (AD) and a higher male frequency in Parkinson’s disease (PD). Conflicting results on gender distribution are reported concerning dementia with Lewy bodies (DLB), usually considered as an intermediate disease between AD and PD. The aim of the present study was to investigate gender differences in DLB in French specialized memory settings using data from the French national database spanning from 2010 to 2015 and to compare sex ratio in DLB with that in AD, Parkinson’s disease dementia (PDD), and PD. Our hypothesis was that there is a balanced sex ratio in DLB, different from that found in AD and PD.

Methods

We conducted a repeated cross-sectional study. The study population comprised individuals with a DLB, AD, PDD, or PD diagnosis according to the International Classification of Diseases, Tenth Revision, in the French National Alzheimer Database between 2010 and 2015. Sex ratio and demographic data were compared using multinomial logistic regression and a Bayesian statistical model.

Results

From 2010 to 2015 in French specialized memory settings, sex ratios (female percent/male percent) were found as follows: 1.21 (54.7%/45.3%) for DLB (n = 10,309), 2.34 (70.1%/29.9%) for AD (n = 135,664), 0.76 (43.1%/56.9%) for PD (n = 8744), and 0.83 (45.4%/54.6%) for PDD (n = 3198). Significant differences were found between each group, but not between PDD and PD, which had a similar sex ratio.

Conclusions

This large-sample prevalence study confirms the balanced gender distribution in the DLB population compared with AD and PD-PDD. Gender distribution and general demographic characteristics differed between DLB and PDD. This is consistent with the hypothesis that DLB is a distinct disease with characteristics intermediate between AD and PD, as well as with the hypothesis that DLB could have at least partially distinct neuropathological correlates.

Liver microbiome of Peromyscus leucopus, a key reservoir host species for emerging infectious diseases in North America

Microbiome studies generally focus on the gut microbiome, which is composed of a large proportion of commensal bacteria. Here we propose a first analysis of the liver microbiome using next generation sequencing as a tool to detect potentially pathogenic strains. We used Peromyscus leucopus, the main reservoir host species of Lyme disease in eastern North America, as a model and sequenced V5-V6 regions of the 16S gene from 18 populations in southern Quebec (Canada). The Lactobacillus genus was found to dominate the liver microbiome. We also detected a large proportion of individuals infected by Bartonella vinsonii arupensis, a human pathogenic bacteria responsible for endocarditis, as well as Borrelia burgdorferi, the pathogen responsible for Lyme disease in North America. We then compared the microbiomes among two P. leucopus genetic clusters occurring on either side of the St. Lawrence River, and did not detect any effect of the host genotype on their liver microbiome assemblage. Finally, we report, for the first time, the presence of B. burgdorferi in a small mammal host from the northern side of the St. Lawrence River, in support of models that have predicted the northern spread of Lyme disease in Canada.

Patient's satisfaction after outpatient forefoot surgery: Study of 619 cases

INTRODUCTION

The number of outpatient surgical procedures performed in France on the forefoot has grown rapidly in recent years.

OBJECTIVES

The goal of this study was to evaluate experience and satisfaction of patients undergoing outpatient foot surgery using a telephone questionnaire developed for this purpose.

MATERIAL AND METHODS

In 2012 and 2013, every patient who was admitted to the day surgery unit at our hospital for an open procedure on their forefoot was called the morning after the procedure. A nurse went through the 14-item questionnaire with the patient. The same perioperative protocol, written instructions and treatment were used for all patients.

RESULTS

Six hundred nineteen patients were included. The questionnaire response rate was 89% (n=540). Isolated hallux valgus surgery was performed on 319 patients (61%); 107 patients (20%) underwent hallux valgus surgery with lateral metatarsal osteotomy; 57 patients (10.5%) underwent first metatarsophalangeal fusion and 47 patients (8.5%) underwent a procedure on the lateral rays only. In the postoperative phase, 65% reported having satisfactory sleep quality, 32% had experienced nausea, 16% had experienced vomiting and 17% had experienced bleeding. Eighty percent of patients experienced pain (VAS ≥ 1); 80% of these patients had their pain relieved by the prescribed treatment and 4% had not taken it. Nearly all the patients (99%) were satisfied with the outpatient care; the overall satisfaction score was 9.4 out of 10. There was a significant relationship between the type of procedure and vomiting, pain, bleeding and fever.

DISCUSSION

Outpatient care is becoming more common in response to economic challenges. The development of outpatient foot surgery appears to have satisfied the vast majority of operated patients. However, adjustments should be made to improve their tolerance to the pain management protocol. Although the logistics of performing follow-up call can be complicated, the patients appreciate receiving this call the next day. The call also seems to reassure both the patients and care providers.

Physical medicine and rehabilitation multidisciplinary approach in a case of posterior cortical atrophy

Posterior cortical atrophy (PCA) is a degenerative syndrome heralded by progressive visual and spatial disorders, while the memory and execution capacities remain preserved for a long time. We report the clinical case of a female patient who received a global Physical and Rehabilitation Medicine (PRM) therapy. Our objective is to highlight the interest of a multidisciplinary approach in PCA. A female patient, LO, 60 years old, presented with visual and spatial difficulties of progressive worsening, while global cognitive efficiency was preserved, signing PCA, with a loss of autonomy in daily life. A six-month multidisciplinary approach (speech therapy, occupational therapy, and physiotherapy) centered on her visual disturbances and associated to the reinforcement of her preserved abilities, as well as a rehabilitation program, was proposed. At the end of this period, LO was again able to read, find efficient exploratory strategies, use the underground, visit museums, have leisure activities, and carry out everyday life activities, which she had ended up abandoning. The specific therapeutic management allowed reaching functional objectives. Our hypothesis is that the absence of other cognitive disorders allowed this type of rehabilitation "contract". The neurodegenerative pathologies responsible for specific instrumental disabilities without global cognitive alteration, and particularly PCA, should be able to benefit from a specific, or even multidisciplinary PMR therapy approach.

Primary aseptic revision of the femoral component of a cemented total hip arthroplasty using a cemented technique without bone graft

BACKGROUND

Primary revisions using cement without bone graft reconstruction are less frequently used because of their supposed higher failure rate. The results, in fact, depend on multiple parameters: number of prior revisions, cementing technique quality, and residual bone stock; these intricate factors are rarely taken together into account when analyzing this treatment method.

HYPOTHESIS

Femoral component fixation with cement can be a valid option in total hip arthroplasty primary revision.

OBJECTIVES

The objective of this investigation was to study the long-term results of cemented femoral stems in total hip arthroplasty primary revisions in terms of the quality of the cementing technique and the residual bone stock.

PATIENTS AND METHODS

This is a retrospective study of a series of 80-cemented primary femoral stems revised for aseptic loosening using a new-cemented femoral stem without bone graft. Seventy implants were analyzed at the longest follow-up. The Postel Merle D'Aubigné and the Harris Hip Scores were used for clinical assessment. The French Academy SOFCOT 99 bone loss grading system was used to classify preoperative bone compromise severity. The Barrack classification assessed the quality of the postoperative cementation. The radiographic study at the last follow-up sought signs of femoral implant loosening classified according to Harris.

RESULTS

The mean follow-up was 10 years and 10 months. The functional evaluation of the hip showed a significant overall gain (p<0.0001) after surgical revision. In our series, the existence of severe grade III or IV bone loss on the SOFCOT 99 classification exposed the patient to a significant risk of intraoperative complications (p=0.03). The grade III and IV femurs had a significantly higher risk (p=0.0001) of having type C or D cementation according to the Barrack classification. Type D cementation was a risk factor for significant iterative radiographic loosening (p=0.005) compared to A, B or C cementations. The 10-year survival rate of the femoral implant was 90% (95% confidence interval [95% CI]: 79.2-94.9%). This survival rate was significantly better (p=0.0016) for revisions with type A or B cementations on the Barrack scale (96% survival; 95% CI: 85.1-99%) than for type C or D (70% survival; 95% CI: 41.4-86.1%).

CONCLUSION

This study shows that revised cemented femoral stems without bone graft added are a valid therapeutic option in primary cemented total hip arthroplasty revisions provided that a good-quality cement technique can be achieved. Sufficient bone stock (SOFCOT 99 grade 0, I or II) was indispensable for good cementation.

LEVEL OF EVIDENCE

IV: therapeutic retrospective study.

[Urethral cancer: report of three cases and review of the literature]

OBJECTIVE

To review the various clinical forms of female urethral cancer in the light of three clinical cases with a review of the corresponding treatment guidelines.

METHOD

The authors report three cases of female urethral cancer. Case 1 consisted of squamous cell carcinoma in a 56-year-old woman with no particular history. Case 2 was a urothelial tumour arising in a urethral diverticulum in a 60-year-old smoker. Case 3 was a 69-year-old woman patient with invasive urothelial carcinoma.

RESULTS

Case 1 was treated by segmental urethrectomy with no adjuvant therapy and a favourable course. Case 2 was treated by anterior pelvic exenteration with no adjuvant therapy. This patient relapsed in the form of peritoneal carcinomatosis two years later and died. Case 3 was initially treated by anterior pelvic exenteration followed by a chemoradiotherapy combination after local recurrence with a favourable course.

CONCLUSION

There are many clinical presentations and histological forms of female urethral cancer. Localized distal lesions can be treated by simple circumferential resection. The treatment of other lesions comprises anterior pelvic exenteration and platinum- or M-VAC-based chemoradiotherapy. The main prognostic factors for these tumours are their size, histological type, site and the presence of pelvic lymph node extension.

[Cerebral infarction, a complication of paroxysmal nocturnal haemoglobinuria]

Paroxysmal nocturnal hemoglobinuria (Marchiafava-Micheli disease) is a rare acquired clonal disorder of the hematopoietic stem cell. Its most frequent clinical manifestations are hemolytic crisis and the most serious are venous thrombosis of the mesenteric, hepatic, portal or cerebral territories. Arterial cerebral infarctions are extremely rare. We report and comment on a case of multiple strokes occurring during an hemolytic crisis and despite effective long-term anticoagulation treatment.

Management of recurrent cervical cancer

Treatment for cervical cancer is very successful, especially in early stages. However, most patients presenting in late stages of disease will experience recurrence. The prognosis of recurrent disease is very poor and treatment options are limited. The diagnosis of recurrence may be apparent or difficult, but determining the extent of disease is always complex. Routine follow-up of asymptomatic patients has other objectives and is not a reliable way to detect recurrences. Symptomatic patients require extensive investigation to detect the extent of the disease. For patients with central pelvic recurrences, exenteration offers the prospect of survival in more than one-third of cases. Newer developments include laterally extended endopelvic resection that may become an option for patients with more extensive pelvic recurrence. For patients with recurrences of cervical cancer, the roles of second-time radiotherapy or postradiation chemotherapy are very limited. Palliative treatment is important for all patients with untreatable disease. Pain relief forms a central part of palliative care. Caregivers also experience emotional feelings and probably function best in a system offering strong colleageal support.

PCR-RFLP using a SNP on the mitochondrial Lsu-rDNA as an easy method to differentiate Tuber melanosporum (Perigord truffle) and other truffle species in cans

Canned truffle products labeled Tuber melanosporum, the famous Perigord truffle, may contain other less tasty and cheaper truffle species. To protect consumers from fraud, a PCR DNA-based method was used to unequivocally identify the nature of the product. Several rapid and simple cell lysis procedures, used in conjunction with a commercially available DNA purification kit, were evaluated for their effectiveness in recovering DNA from canned truffle. In parallel, a marker for T. melanosporum was tested on the mitochondrial rDNA. These two techniques were then combined to differentiate T. melanosporum from other truffle species like T. aestivum, T. brumale or T. indicum up to the legal threshold in canned products. These findings not only allow a comparison of the effectiveness of the different DNA extraction methods but also provide a preliminary indication of the specificity and sensitivity of the detection with the mitochondrial marker that might be attainable for truffle species in a quantitative PCR-based analysis method.

Salvage of immature forearm fistulas for haemodialysis by interventional radiology

BACKGROUND

The goal of this article is to assess the value of endovascular techniques for the salvage of fistulas that fail to mature.

METHODS

Over a 6-year period, 52 dysfunctional and 17 thrombosed immature forearm fistulas (mean age 10 weeks) were treated by interventional radiology. Angiography was performed by puncture of the brachial artery but dilation of underlying stenoses was performed after cannulation of the fistula itself, whenever possible, with a balloon never smaller than 5 mm. Embolization or ligation of any type of vein was never indicated and never performed. For thrombosed fistulas, significant clots were removed by manual catheter-directed aspiration. A covered stent (Passager) was used in cases of dilation-induced rupture not controlled by balloon tamponade.

RESULTS

An underlying stenosis was diagnosed in 100% of cases. Half of them were located in the anastomotic area. The initial success rate of interventional radiology was 97%. Dilation-induced rupture occurred in nine cases (13%) but stents were necessary in only two cases. The rate of significant clinical complications was 2.8% (bacteraemia, pseudoaneurysm). Primary and secondary patency rates at 1 year were 39 and 79%, respectively.

CONCLUSIONS

Delayed maturation of native fistulas should lead systematically to imaging as an underlying stenosis is diagnosed in all cases. Interventional radiology can treat the majority of cases and achieve a 97% success rate but early recurrence of stenoses can occur. Multidisciplinary re-evaluation of the patient must, therefore, be performed after radiological salvage of the fistula.

Treatment of stenosis and thrombosis in haemodialysis fistulas and grafts by interventional radiology

BACKGROUND

There are no large series reporting the long-term results after radiological treatment of both stenosis and thrombosis in native fistulas (AVFs) and prosthetic grafts.

METHODS

Between 1987 and 1999, 726 dilations, 135 stent placements and 257 declotting procedures were performed in 209 consecutive forearm AVFs, 74 upper arm AVFs and 156 prosthetic grafts. The stents used were the Wallstent*, the Craggstent*, and the Passager*. Declotting was performed by manual catheter-directed thromboaspiration, with or without previous urokinase infusion.

RESULTS

The initial success rates ranged from 78 to 98%. The rate of significant complications was 2%. Primary patency rates at 1 year were twice as good for forearm AVFs (50%) than for grafts (25%) (P<0.05), and were 34% for upper arm AVFs. Secondary patency rates were similar in the 3 groups at 1 year (80-86%) and at 2 years (68-80%). Reintervention was necessary every 18 months in forearm AVFs compared to every 9 months in grafts (P<0.05). Thrombosed grafts fared worse than failing grafts. Accesses of less than 1 year's duration needed more reinterventions than older accesses (every 16 months versus 30 in forearm AVFs, every 7 months versus 13 in grafts, P<0.05).

CONCLUSIONS

The percutaneous treatment of stenosis and thrombosis in haemodialysis access achieves patency rates similar to those reported in the surgical literature and confirms that grafts must be avoided as much as possible given their poorer outcome, especially after the first thrombosis. Poorer outcome is also demonstrated in accesses of less than 1 year's duration.

Wallstents and Craggstents in hemodialysis grafts and fistulas: results for selective indications

PURPOSE

To report the value of selective placement of self-expandable stents (Wallstent and Craggstent) for the treatment of limitations and, occasionally, of complications of dilation in hemodialysis access, and especially for delaying restenosis.

MATERIALS AND METHODS

This is a retrospective study of a 7-year period, during which 41 Wallstents and 11 Craggstents were placed in 26 polytetrafluoroethylene (PTFE) grafts, 15 native fistulas, and nine central veins of 47 patients. The indications were stenosis recoil (n = 13), recurrent restenosis within 6 months (n = 33), restenosis after 6 months (n = 3), and acute angioplasty-induced rupture (n = 1). Restenosis after stent placement necessitated redilation and percutaneous declotting and 10 additional stent placements.

RESULTS

Two initial misplacements were corrected immediately. Primary patency rates for PTFE grafts were 58% +/- 10% at 6 months and 23% +/- 10% at 1 year, respectively. Secondary patency rates were 100% at 6 months and 88% +/- 8% at 1 year, respectively. For native fistulas, primary patency rates were 47% +/- 12% at 6 months and 20% +/- 18% at 1 year. Secondary patency rates were 95% +/- 6% at 6 months and 79% +/- 14% at 1 year. It was necessary to reintervene after stent placement to maintain or to restore patency every 9 months for PTFE grafts and every 7.3 months for native fistulas. When stents were placed for treatment of early recurring restenosis, the mean interval between radiologic interventions (redilations or declottings) performed to maintain or to restore patency before stent placement was multiplied by 2.1 after stent placement for both grafts (3.2 months increased to 6.9, P < .01) and native fistulas (2.9 months increased to 6.2, P < .02).

CONCLUSIONS

Wallstents and Craggstents are valuable for the treatment of failure of regular dilation and they double the intervals between reinterventions for early (< 6 months) recurring stenoses in PTFE grafts and native fistulas.

Manual thromboaspiration and dilation of thrombosed dialysis access: mid-term results of a simple concept

PURPOSE

To report the feasibility, safety, and effectiveness of manual thromboaspiration as a single means of declotting dialysis access.

MATERIALS AND METHODS

Between April 1994 and December 1996, 59 consecutive conduits (43 polytetrafluoroethylene [PTFE] grafts, 16 native fistulas) were declotted with 8-F or 7-F angulated catheters. Unmasked stenoses were dilated. Clinical and paraclinical nephrologic surveillance (poor flow, palpation, difficulties with cannulation, increased compression times, increasing venous pressures) led to redilations and stent placements. Rethromboses were treated with further declotting by aspiration. The results are presented according to the life-table method.

RESULTS

The initial success of 43 of 43 PTFE grafts (mean procedure time, 119 min +/- 29 [standard deviation]) led to a primary patency rate of 85% +/- 5% (SE) at 1 month, 33% +/- 8% at 6 months, and 24% +/- 12% at 1 year. A graft was ligated 6 days after declotting for acute bleeding in one patient given high-dose warfarin. The secondary patency rates were 86% +/- 7% at 6 months and 86% +/- 9% at 1 year, with a mean duration of patency of 5.7 months between two radiologic interventions performed to maintain or to restore patency, and 19 stents were placed at a mean follow-up of 3 months. The success rate was 81% for native fistulas, with primary patency rates of 81% +/- 10% at 1 month, 74% +/- 14% at 6 months, and 60% +/- 27% at 1 year; secondary patency rates of 81% +/- 12% at 6 months and 81% +/- 18% at 1 year.

CONCLUSION

Thromboaspiration is a safe and effective method for declotting dialysis access, yielding a low rethrombosis rate during the first month. Overall radiologic management with reintervention on average every 6 months results in high secondary patency rates at 1 year (81%-86%).

[Evaluation of a tool for developmental disorder screening in 4-year-old children]

With the aim of helping physicians working in a "Mother and Infant Protection Service" (PMI) in their mission of children's development difficulties screening, authors tried to assess performances of a clinical tool including parental informations and standardized tests. The whole four years old children going at school in a canton of Calvados department were independently examined by a PMI doctor using the tool to be estimated and by a specialized service working from a beforehand established protocol. For the language disorders on the one hand and the adaptation on the other hand, this evaluation shows a significant correlation between the PMI screening and the specialists one's: the sensitivity of the PMI examination is about 70% for those two types of difficulties with a positive predictive value respectively 28% and 57%. However the tool appears less reliable for the psychomotor disorders screening: only one quarter of the children who require a specialized investigation about these problems have been detected by the PMI screening. A filing and a selection of the questionnaire items should permit to improve the efficiency of this tool.

Increased norepinephrine variability in patients with sleep apnea syndrome

OBJECTIVE

To assess the plasma arterial catecholamine response to nocturnal desaturation in a group of patients with a history suggestive of sleep apnea.

PATIENTS AND METHODS

At a Veterans Affairs hospital, 10 patients who had a history consistent with sleep apnea syndrome were involved in the study. Arterial plasma catecholamines were measured at varying intervals during a 5 1/2-hour sleep study. Eighteen samples per patient were analyzed.

RESULTS

As the hemoglobin saturation decreased, the variability in plasma norepinephrine increased significantly (r = -.78, P = 0.004). As the hemoglobin saturation fell, there was a trend towards higher concentrations of plasma norepinephrine (r = -.53, P = 0.06). As the hemoglobin saturation decreased, the variability in plasma epinephrine concentration was not significant (r = .42).

CONCLUSION

The association between the degree of desaturation and the variability in norepinephrine suggests that norepinephrine is released in response to nocturnal desaturation.

Delta sleep-inducing-peptide-like immunoreactivity (DSIP-LI) and delta sleep in schizophrenic volunteers

Delta sleep-inducing-peptide (DSIP) has been reported to increase sleep in subjects with insomnia. The authors studied cerebrospinal fluid (CSF) DSIP-like immunoreactivity (DSIP-LI) in 15 drug-free male subjects with a DSM-IIIR diagnosis of schizophrenia. The subjects underwent a lumbar puncture and three nights of polysomnography. CSF DSIP-LI was significantly correlated with polysomnography the night before the LP: with stage 3 sleep (p = 0.05), stage 3 and delta (stages 3 + 4) sleep during the first nonrapid eye movement NREM period (p = 0.02 and p = 0.05, respectively) and the ratio of the first and second NREM period (p < 0.05), and negatively with stage 2% sleep (p < 0.05). Whether this first report of a potential relationship between CSF DSIP-LI and slow-wave sleep in man might be generalized to sleep in nonpsychiatric subjects awaits further study.

Deterioration in premorbid functioning in schizophrenia: a developmental model of negative symptoms in drug-free patients

OBJECTIVE

The authors examined the relationship between negative symptoms and premorbid variables in drug-free schizophrenic patients.

METHOD

The authors studied 63 clinically stable male schizophrenic inpatients who were not receiving any psychoactive medication. The patients were classified as having negative, positive, or mixed symptoms, and their premorbid functioning during childhood, early adolescence, and late adolescence was assessed by using the Premorbid Adjustment Scale. Correlational analyses were applied to the classification and developmental models.

RESULTS

Patients with negative symptoms had significantly lower levels of premorbid functioning during late adolescence and significantly greater premorbid deterioration between childhood and early adolescence. Correlational analysis revealed significant positive relationships between premorbid variables and negative symptoms.

CONCLUSIONS

The data suggest that a deterioration in social and intellectual functioning between childhood and adolescence is associated with the development of a negative symptom syndrome in schizophrenia. The premorbid deterioration appears to be an early prodrome of the disorder. Whether this residual negative symptom syndrome is in some way related to the deficit syndrome of schizophrenia awaits a prospective study.

CSF chromogranin A-like immunoreactivity in schizophrenia: relationships with REM latency and slow wave sleep

Chromogranin A (CgA) is a calcium binding protein and a precursor of modulatory peptides in the brain. We measured CgA-like immunoreactivity (CgA-LI) in cerebrospinal fluid (CSF) in 15 male schizophrenic patients (diagnosed by DSM-III-R criteria) after 3 nights of polysomnography. Patients had been drug free for at least 33 days. Our earlier report that CSF CgA-LI in schizophrenic patients correlated significantly with negative symptoms and ventricle-brain ratios, which have been related to slow wave sleep, raised the possibility that CgA-LI might relate to slow wave sleep. CSF CgA-LI was significantly correlated with stage 4 sleep and rapid eye movement latency. Whether these positive relationships between CSF CgA-LI and electroencephalographic sleep measures are specific for schizophrenia awaits further study.