Successful twin pregnancy in a woman undergoing alternate diurnal and nocturnal hemodialysis

Although pregnancy has become more frequent in patients undergoing hemodialysis, it remains a relatively rare event and carries a high risk of complications for both the mother and the fetus. In parallel, multiple pregnancies are also associated with a high risk of complications for the mother and the fetus, even in healthy women. The presence of a twin pregnancy in a woman with chronic renal failure undergoing hemodialysis is an even rarer event and is considered a very high-risk situation. We describe the case of a 31-year-old hemodialysis patient who successfully gave birth to twins at 29 weeks after a period of alternate diurnal and nocturnal hemodialysis.

Serum S100B Level in the Management of Pediatric Minor Head Trauma: A Randomized Clinical Trial

Importance

Minor head trauma (HT) is one of the most common causes of hospitalization in children. A diagnostic test could prevent unnecessary hospitalizations and cranial computed tomographic (CCT) scans.

Objective

To evaluate the effectiveness of serum S100B values in reducing exposure to CCT scans and in-hospital observation in children with minor HT.

Design, Setting, and Participants

This multicenter, unblinded, prospective, interventional randomized clinical trial used a stepped-wedge cluster design to compare S100B biomonitoring and control groups at 11 centers in France. Participants included children and adolescents 16 years or younger (hereinafter referred to as children) admitted to the emergency department with minor HT. The enrollment period was November 1, 2016, to October 31, 2021, with a follow-up period of 1 month for each patient. Data were analyzed from March 7 to May 29, 2023, based on the modified intention-to-treat and per protocol populations.

Interventions

Children in the control group had CCT scans or were hospitalized according to current recommendations. In the S100B biomonitoring group, blood sampling took place within 3 hours after minor HT, and management depended on serum S100B protein levels. If the S100B level was within the reference range according to age, the children were discharged from the emergency department. Otherwise, children were treated as in the control group.

Main Outcomes and Measures

Proportion of CCT scans performed (absence or presence of CCT scan for each patient) in the 48 hours following minor HT.

Results

A total of 2078 children were included: 926 in the control group and 1152 in the S100B biomonitoring group (1235 [59.4%] boys; median age, 3.2 [IQR, 1.0-8.5] years). Cranial CT scans were performed in 299 children (32.3%) in the control group and 112 (9.7%) in the S100B biomonitoring group. This difference of 23% (95% CI, 19%-26%) was not statistically significant (P = .44) due to an intraclass correlation coefficient of 0.32. A statistically significant 50% reduction in hospitalizations (95% CI, 47%-53%) was observed in the S100B biomonitoring group (479 [41.6%] vs 849 [91.7%]; P < .001).

Conclusions and Relevance

In this randomized clinical trial of effectiveness of the serum S100B level in the management of pediatric minor HT, S100B biomonitoring yielded a reduction in the number of CCT scans and in-hospital observation when measured in accordance with the conditions defined by a clinical decision algorithm.

Trial Registration

ClinicalTrials.gov Identifier: NCT02819778.

Improving Audiology Student Training by Clinical Simulation of Tinnitus: A Glimpse of the Lived Experience of Tinnitus

PURPOSE

Student audiology training in tinnitus evaluation and management is heterogeneous and has been found to be insufficient. We designed a new clinical simulation laboratory for training students on psychoacoustic measurements of tinnitus: one student plays the role of the tinnitus patient, wearing a device producing a sound like tinnitus on one ear, while another student plays the role of the audiologist, evaluating their condition. The objective of the study was to test this new clinical simulation laboratory of tinnitus from the perspective of the students.

METHOD

This study reports the findings from twenty-one audiology students (20 female and 1 male, mean age = 29, SD = 7.7) who participated in this laboratory for a mandatory audiology class at the Laval University of Quebec. Three students had hearing loss (one mild, two moderate). All students played the role of both the clinician and the patient, alternately. They also had to fill out a questionnaire about their overall experience of the laboratory.

RESULTS

The qualitative analysis revealed three main themes: "Benefits of the laboratory on future practice", "Barriers and facilitators of the psychoacoustic assessment", and "Awareness of living with tinnitus". The participants reported that this experience would have a positive impact on their ability to manage tinnitus patients in their future career.

CONCLUSION

This fast, cheap, and effective clinical simulation method could be used by audiology and other healthcare educators to strengthen students' skills and confidence in tinnitus evaluation and management. The protocol is made available to all interested parties.

Amplification of the poorer ear by StereoBiCROS in case of asymmetric sensorineural hearing loss: effect on tinnitus

Tinnitus is prevalent among patients suffering from Single-Sided Deafness (SSD) and Asymmetrical Hearing Loss (AHL). In addition to bothersome tinnitus in the poorer ear, these patients also report issues with understanding speech in noise and sound localization. The conventional treatment options offered to these patients to improve auditory abilities are cochlear implantation, bone conduction devices or Contralateral Routing Of Signal (CROS) hearing aids. It was recently found that the benefit of cochlear implantation for tinnitus associated with AHL/SSD was greater than the other two approaches. It is conceivable that the lack of stimulation provided to the poorer ear in these last approaches explains their modest impact on tinnitus perception. A new technology that combines the ability to reroute the sound from the poorer ear to the good ear (CROS system) while still stimulating the poorer ear with conventional sound amplification has recently been developed: the StereoBiCROS system. The aim of this study was to investigate the effects of this new device on tinnitus. Twelve AHL and two SSD patients aged 70.7 ± 7.9 years with tinnitus were fitted with bilateral hearing aids that included 3 programs: Stereophonic, BiCROS and StereoBiCROS (CROS + bilateral amplification). The short-and long-term effect of the approach on tinnitus was assessed using a tinnitus Loudness Visual Analog Scale (VAS) and the Tinnitus Handicap Inventory (THI), respectively. Both the VAS and the THI were used before and one month after the hearing aid fitting. Of the 14 patients who used their hearing aids daily (12.6 ± 1.6 h per day) the StereoBiCROS program was the most used program (81.8 ± 20.5% of the time). The average THI total score decreased from 47 (± 22) to 15 (± 16) (p = 0.002) and the VAS-Loudness score decreased from 7 (± 1) to 2 (± 2) (p < 0.001) after the one-month trial period. In conclusion, StereoBiCROS stimulation strategy seems to offer an effective alternative to reduce tinnitus handicap and loudness for patients with AHL/SSD and tinnitus. This effect may be driven by sound amplification of the poorer ear.

Ultra-fast remote up-titration of heart failure treatment: a safe, efficient and feasible protocol

Introduction

Heart failure (HF) is a common disease with a significant economic burden, mainly caused by HF hospitalisations and significant morbi-mortality. Nevertheless, HF patients are still undertreated due to a clinical inertia that needs to be reversed as soon as possible using new, safe and available methods. Remote up-titrating HF medication might be the solution to rapidly optimize HF treatment to maximal tolerated doses.

Purpose

Our objective was to describe the safety, efficacy and feasibility of an ultra-fast remote up-titration protocol of HF treatment.

Methods

Patients with a recent hospitalization due to a HF decompensation and left ventricular ejection fraction &lt;50% were retrospectively included in our database. We collected clinical, biological and treatment data at enrollment and at the end of HF medication optimization. Our protocol consisted in remote consultation (via telephone or video-consultation) every 15 days with a 72h prior blood test. Blood pressure (BP), heart rate (HR) and weight were recorded either by tele-monitoring or self-measurement.

Results

We evaluated 96 patients, 25% female with a mean LVEF at 29%, main etiology of HF was ischemic (48%) and mean NTproBNP was 2384 pg/mL. Mean BP was 112/70 mmHg, HR was 73 bpm, glomerular filtration rate (GFR) 71 ml/min and potassium concentration was 4,4 mEq/L. Ninety four patients were initially treated with a beta blocker (BB), 29% of our cohort was treated either with an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB) and 59% was treated with angiotensin receptor neprilysin inhibitor (ARNI). A total of 72 patients were treated with a mineralocorticoid receptor antagonist (MRA) and 58 patients were also treated with an inhibitor of sodium-glucose transport protein 2 (SLGT2i), Figure 1. Median duration of tele-titration consultation was 42 days. We up-titrated BB in 50% of our patients, of which 10% were at maximum dose, making a total of 98% of our cohort under BB treatment. Sixty percent of patients under ACEI or ARB were switched to ARNI. Of the 82% of patients under ARNI, up to 50% achieved the maximal dose.

We introduced or up-titrated ARM in 41 patients, reaching the target dose in 37%. Dose variations and mean initial and final doses are shown in Figure 2.1 and 2.2

Minor adverse events that motivated a down-titration or a cessation of treatment were, hyperkalemia 5%, acute renal failure (ARF) 6%, hypotension 3% and bradycardia 2%. Non urgent hospitalization due to ARF with hyperkalemia or HF only occurred in 2 cases.

The limiting factors for not reaching the optimal targeted dose were low HR in 20%, hypotension in 11%, high concentration of potassium 10% and chronic renal failure in 9%.

Conclusion

Remote up-titration of HF medication is a promising tool in the fight against clinical inertia and a fast, feasible, safe (only 2% of major events) and efficient solution to our undertreated patients.

Funding Acknowledgement

Type of funding sources: None.

Benefits of interventional telemonitoring in patients with chronic heart failure

Background

The aim of this study was to assess the effect of interventional specialized Telemonitoring (ITM) compared to standard telemonitoring (STM) and standard of care (SC) on preventing all causes of death, cardiovascular mortality and unplanned hospitalization in heart failure (HF) patients.

Methods and results

414 HF-patients derived from two French cohorts (OSICAT and ETAPES) were included in this study, and subsequently randomized into three groups ITM-group (n=220), STM-group (n=99) and SC-group (n=95). The telemonitoring was performed by the specialized HF-cardiology staff at a university hospital. During the mean follow-up period of 344 days, there were significantly fewer primary endpoints like unplanned hospitalization (13.6% vs 34.3% vs 36.8%, p&lt;0.05), all-cause of death (4.5% vs 20.2% vs 16.8%, p&lt;0.05) and cardiovascular mortality (3.2% vs 15.2% vs 8.4%, p&lt;0.05) in the ITM-group. The multivariate logistic regression revealed a significant negative association between the ITM and unplanned hospitalization (OR=0.293 95% CI [0.160–0.535], p&lt;0.05) and all-cause of death (OR=0.243 95% CI [0.099–0.596], p=0.002), respectively. Kaplan Meier and log rank test showed significant difference in median event-free survival in favor of ITM-group.

Conclusions

Using ITM to follow-up HF-patients results in reducing the rate of unplanned hospitalization and all cause of death.

Funding Acknowledgement

Type of funding sources: None.

Exploring the middle ear function in patients with a cluster of symptoms including tinnitus, hyperacusis, ear fullness and/or pain

Middle ear muscle (MEM) abnormalities have been proposed to be involved in the development of ear-related symptoms such as tinnitus, hyperacusis, ear fullness, dizziness and/or otalgia. This cluster of symptoms have been called the Tonic Tensor Tympani Syndrome (TTTS) because of the supposed involvement of the tensor tympani muscle (TTM). However, the putative link between MEM dysfunction and the symptoms has not been proven yet and the detailed mechanisms (the causal chain) of TTTS are still elusive. It has been speculated that sudden loud sound (acoustic shock) may impair the functioning of the MEM, specifically the TTM, after an excessive contraction. This would result in inflammatory processes, activation of the trigeminal nerve and a change of the MEMs state into a hypersensitive one, that may be associated to the cluster of symptoms listed above. The goal of this study is to provide further insights into the mechanisms of TTTS. The middle ear function of 11 patients who reported TTTS symptoms has been investigated using either admittancemetry and/or measurement of air pressure in the sealed external auditory canal. While the former method measured the middle ear stiffness the latter provides an estimate of the tympanic membrane displacement. Most patients displayed results consistent with phasic contractions of the TTM (n = 9) and/or Eustachian Tube (ET) dysfunction (n = 6). The MEM contraction or ET dysfunction could be evoked by acoustic stimulation (n = 3), somatic maneuvers (n = 3), or pressure changes in the ear canal (n = 3). Spontaneous TTM contraction (n = 1) or ET opening (n = 1) could also be observed. Finally, voluntary contraction of MEM was also reported (n = 5). On the other hand, tonic contraction of the TTM could not be observed in any patient. The implications of these results for the mechanisms of TTTS are discussed.

A psychoacoustic test for misophonia assessment

Misophonia is a condition where a strong arousal response is triggered when hearing specific human generated sounds, like chewing, and/or repetitive tapping noises, like pen clicking. It is diagnosed with clinical interviews and questionnaires since no psychoacoustic tools exist to assess its presence. The present study was aimed at developing and testing a new assessment tool for misophonia. The method was inspired by an approach we have recently developed for hyperacusis. It consisted of presenting subjects (n = 253) with misophonic, pleasant, and unpleasant sounds in an online experiment. The task was to rate them on a pleasant to unpleasant visual analog scale. Subjects were labeled as misophonics (n = 78) or controls (n = 55) by using self-report questions and a misophonia questionnaire, the MisoQuest. There was a significant difference between controls and misophonics in the median global rating of misophonic sounds. On the other hand, median global rating of unpleasant, and pleasant sounds did not differ significantly. We selected a subset of the misophonic sounds to form the core discriminant sounds of misophonia (CDS_Miso). A metric: the CDS score, was used to quantitatively measure misophonia, both with a global score and with subscores. The latter could specifically quantify aversion towards different sound sources/events, i.e., mouth, breathing/nose, throat, and repetitive sounds. A receiver operating characteristic analysis showed that the method accurately classified subjects with and without misophonia (accuracy = 91%). The present study suggests that the psychoacoustic test we have developed can be used to assess misophonia reliably and quickly.

A contribution to the debate on tinnitus definition

Tinnitus is generally defined as an auditory perception in the absence of environmental sound stimulation. However, this definition is quite incomplete as it omits an essential aspect, the patient's point of view. This point of view constitutes, first and foremost, a global and unified lived experience, which is not only sensory (localization, loudness, pitch and tone), but also cognitive (thoughts, attentiveness, behaviors) and emotional (discomfort, suffering). This experience can be lived in a very unpleasant way and consequently have a very negative impact on quality of life. This article proposes and justifies a new definition for tinnitus elaborated by a group of French clinicians and researchers, which is more in line with its phenomenology. It also provides a minimum knowledge base, including possibilities for clinical care, hoping to eradicate all misinformation, misconceptions and inappropriate attitudes or practices toward this condition. Here is the short version of our definition: Tinnitus is an auditory sensation without an external sound stimulation or meaning, which can be lived as an unpleasant experience, possibly impacting quality of life.

Modulation of hyperacusis and tinnitus loudness in tinnitus patients with and without hearing loss following 3 weeks of acoustic stimulation: A proof-of-concept study

Tinnitus and hyperacusis are two debilitating conditions that are highly comorbid. It has been postulated that they may originate from similar pathophysiological mechanisms such as an increase in central gain. Interestingly, sound stimulation has been shown to reduce central gain and is currently used for the treatment of both conditions. This study investigates the effect of sound stimulation on both tinnitus and hyperacusis in the same patients. Two distinct series of tinnitus participants were tested: one with normal or near-normal hearing (n=16) and one with hearing loss (n=14). A broadband noise shaped to cover most of the tinnitus frequency spectrum was delivered through hearing aids using the noise generator feature (no amplification) and verified through real-ear measurements. Participants received sound stimulation for 3 weeks and were tested before (at baseline), then after 1 week and at the end of the 3 weeks of sound stimulation. There was also a 1-month follow-up after the end of the stimulation protocol. The measurements included self-reported measures of tinnitus and hyperacusis (VAS), validated questionnaires (THI, HQ) and psychoacoustic measurements (tinnitus battery and loudness functions). On both self-assessment (VAS of sound tolerance and tinnitus loudness) and psychoacoustic measures (loudness function and tinnitus loudness in dB), about 50% of tinnitus participants had a synchronous (either a decrease or an increase) modulation of hyperacusis and tinnitus loudness after 1 week and 3 weeks of acoustic stimulation and up to about 70% of participants at 1-M follow-up. The decrease of hyperacusis and tinnitus loudness was more prevalent in normal-hearing participants. There was a significant increase in tinnitus loudness during and following the stimulation in the group with hearing loss. Hyperacusis improvement as assessed by loudness function was significantly correlated with the intensity level of the acoustic stimulation (dB level of the noise produced by the noise generator) in tinnitus participants with normal/near-normal hearing thresholds. Our study partly supports the central gain hypothesis by showing synchronous modulation of hyperacusis and tinnitus loudness. It also shows beneficial effects of acoustic stimulation in some tinnitus individuals, in particular those with normal or near-normal hearing, while highlighting the importance of a careful fitting of sound generators to prevent increase. Since the amplification feature was not turned on in our study, future work should determine whether amplification alone, or in addition to acoustic stimulation (sound generators), would benefit to those with hearing loss.

The gap prepulse inhibition of the acoustic startle (GPIAS) paradigm to assess auditory temporal processing: Monaural versus binaural presentation

The Gap Prepulse Inhibition of the Acoustic Startle Reflex (GPIAS) is a paradigm used to assess auditory temporal processing in both animals and humans. It consists of the presentation of a silent gap embedded in noise and presented a few milliseconds before a startle sound. The silent gap produces the inhibition of the startle reflex, a phenomenon called gap-prepulse inhibition (GPI). This paradigm is also used to detect tinnitus in animal models. The lack of inhibition by the silent gaps is suggested to be indicative of the presence of tinnitus "filling-in" the gaps. The current research aims at improving the GPIAS technique by comparing the GPI produced by monaural versus binaural silent gaps in 29 normal-hearing subjects. Two gap durations (5 or 50 ms), each embedded in two different frequency backgrounds (centered around 500 or 4 kHz). Both low- and high- frequency narrowband noises had a bandwidth of half an octave. Overall, the startle magnitude was greater for the binaural versus the monaural presentation, which might reflect binaural loudness summation. In addition, the GPI was similar between the monaural and the binaural presentations for the high-frequency background noise. However, the GPI was greater for the low-frequency background noise for the binaural, compared to the monaural, presentation. These findings suggest that monaural GPIAS might be more suited to detect tinnitus compared to the binaural presentation.

The difference in poststimulus suppression between residual inhibition and forward masking

The phenomenon of tinnitus masking (TM) and residual inhibition (RI) of tinnitus are two ways to investigate how external sounds interact with tinnitus: TM provides insight on the fusion between external sound activity and tinnitus related activity while RI provides insight on how the external sound might suppress the tinnitus related activity for a period of time. Differences in masking level between the tinnitus and an external tone with tinnitus characteristics (frequency, loudness) have previously shown a high level of heterogeneity. The difference in poststimulus suppression between the two, that is, residual inhibition for the former, and forward masking for the latter, has never been explored. This study aims to investigate minimum masking levels (MMLs) and minimum residual inhibition levels (MRILs) of tinnitus and of an external tone mimicking tinnitus while using diotic and dichotic noises. Pulsed narrowband noises (1 octave width and centered at 1kHz, frequency of the hearing loss slope, tinnitus frequency) and white noise were randomly presented to 20 tinnitus participants and 20 controls with an external tone mimicking tinnitus (4kHz, intensity level corresponding to tinnitus loudness). The MML values obtained for the masking of tinnitus and for the mimicking external sounds were very similar. On the other hand, the MRILs were significantly different between the tinnitus and the mimicking external sounds within tinnitus participants. They were also different between the tinnitus participants and the controls. Overall, for both within and between comparisons, the MRIL values were much higher to produce a poststimulus suppression for the mimicking sound than for the tinnitus. The results showed no significant differences between the diotic and dichotic conditions. These results corroborate other findings suggesting that the tinnitus-related neural activity is very different from the stimulus-related neural activity. The consequences of this last finding are discussed.

IgA Nephropathy Associated with Trifluridine/Tipiracil: A Case Report

Kidney diseases during chemotherapy treatment are variable, with different manifestations depending on the drugs used. Trifluridine/tipiracil is a treatment used in refractory metastatic digestive cancers. Its renal toxicity is poorly described. We report here the onset of a severe IgA nephropathy requiring hemodialysis which occurred several weeks after trifluridine/tipiracil treatment.

Natural History of Perianal Fistulising Lesions in Patients With Elderly-onset Crohn's Disease: A Population-based Study

INTRODUCTION

Most studies of elderly-onset Crohn's disease [CD; diagnosed in patients aged 60 or over] have described a mild course. However, data on the natural history of perianal fistulising CD [pfCD] in this population are scarce. In a population-based cohort study, we described the prevalence, natural history, and treatment of pfCD in patients with elderly-onset CD vs patients with paediatric-onset CD.

METHOD

All patients diagnosed with CD at or after the age of 60 between 1988 and 2006, were included [n = 372]. Logistic regression, Cox models, and a nested case-control method were used to identify factors associated with pfCD.

RESULTS

A total of 34 elderly patients [9% of the 372] had pfCD at diagnosis. After a median follow-up of 6 years (interquartile range [IQR]: 3; 10), 59 patients [16%] had pfCD; the same prevalence [16%] was observed in paediatric-onset patients. At last follow-up, anal incontinence was more frequent in elderly patients with pfCD than in elderly patients without pfCD [22% vs 4%, respectively; p < 10-4]. Rectal CD at diagnosis was associated with pfCD: hazard ratio (95% confidence interval [CI] = 2.8 [1.6-5.0]). Although 37% of the patients received immunosuppressants and 17% received anti-tumour necrosis factor agents, 24% [14 out of 59] had a definitive stoma at last follow-up.

CONCLUSION

During the first 6 years of disease, the prevalence of pfCD was similar in elderly and paediatric patients. Rectal involvement was associated with the appearance of pfCD in elderly-onset patients. Around a quarter of patients with elderly-onset CD will have a stoma. Our results suggest that treatment with biologics should be evaluated in these patients.

Comparing Tinnitus Tuning Curves and Psychoacoustic Tuning Curves

Tinnitus masking patterns have long been known to differ from those used for masking external sound. In the present study, we compared the shape of tinnitus tuning curves (TTCs) to psychophysical tuning curves (PTCs), the latter using as a target, an external sound that mimics the tinnitus characteristics. A secondary goal was to compare sound levels required to mask tinnitus to those required to mask tinnitus-mimicking sounds. The TTC, PTC, audiometric thresholds, tinnitus pitch, and level matching results of 32 tinnitus patients were analyzed. Narrowband noise maskers were used for both PTC and TTC procedures. Patients were categorized into three groups based on a combination of individual PTC-TTC results. Our findings indicate that in 41% of cases, the PTC was sharp (V shape), but the TTC showed a flat configuration, suggesting that the tinnitus-related activity in that subgroup does not behave as a regular stimulus-induced activity. In 30% of cases, V-shape PTC and TTC were found, indicating that the tinnitus-related activity may share common properties with stimulus-induced activity. For a masker centered at the tinnitus frequency, the tinnitus was more difficult to mask than the mimicking tone in 72% of patients; this was particularly true for the subset with V-shape PTCs and flat TTCs. These results may have implications for subtyping tinnitus and acoustic therapies, in particular those targeting the tinnitus frequency.

Audiologists and Tinnitus

Purpose Although tinnitus is highly prevalent among patients receiving audiology services, audiologists are generally untrained in tinnitus management. Audiology graduate programs, as a rule, do not provide comprehensive instruction in tinnitus clinical care. Training programs that do exist are inconsistent in their recommendations. Furthermore, no standards exist to prevent the delivery of unvetted audiologic services, which can be expensive for patients. Patients seeking professional services by an audiologist, therefore, have no basis upon which to be assured they will receive research-based care. The purpose of this article is to describe the current status of tinnitus management services that exist within the general field of audiology and to suggest specific approaches for improving those services. Conclusion Audiologists may be in the best position to serve as the primary health care providers for patients experiencing tinnitus. Tinnitus care services by audiologists, however, must achieve a level of evidence-based standardization.

P3360Quantitative assessment of tricuspid regurgitation using right and left ventricular stroke volumes obtained from tomographic equilibrium radionuclide ventriculography

Background

Quantitative assessment of valve regurgitation using volumetric method by comparing right and left ventricular stroke volumes is still under investigations.

Aims

To investigate the accuracy of tomographic equilibrium radionuclide ventriculography (t-ERV) for the quantification of tricuspid regurgitation (TR).

Methods and results

Sixty-one patients (44 men; mean age 59±12 years) who underwent both t-ERV and transthoracic echocardiography (TTE) studies within 2 weeks for right ventricular systolic function assessment were eligible for inclusion. A sub-group of 22 patients underwent both t-ERV and CMR. Patients with mitral/aortic regurgitation by TTE were excluded of the study. TR regurgitant volume (RVol) was calculated using the proximal isovelocity surface area (PISA) method from TTE and the volumetric method (right ventricular stroke volume minus left ventricular stroke volume) from t-ERV. RVol tended to be higher using the ERV volumetric method as compared to PISA method (43±35 and 35±33 ml, respectively; P<0.0001). There was a significant correlation between RVol as assess by ERV and by TTE (R=0.95, P<0.0001). Intraclass correlation coefficient between TTE and ERV for TR quantification was 0.95 (P<0.0001). Among patients who underwent CMR, the correlation between RVol obtained by TTE and by t-ERV and CMR were R=0.81 and R=0.75, respectively (all P<0.0001), without difference between the two correlations (P=0.263).

Linear regression (left) and Bland-Altma

Conclusion

TR assessment using the t-ERV correlates well with PISA from TTE in patients referred for right ventricular systolic function assessment.

A New Method for Assessing Masking and Residual Inhibition of Tinnitus

Tinnitus masking and residual inhibition (RI) are two well-known psychoacoustic measures of tinnitus. While it has long been suggested that they may provide diagnostic and prognostic information, these measures are still rarely performed in clinics, as they are too time consuming. Given this issue, the main goal of the present study was to validate a new method for assessing these measures. An acoustic sequence made of pulsed stimuli, which included a fixed stimulus duration and interstimulus interval, was applied to 68 tinnitus patients at two testing sites. First, the minimum masking level (MML) was measured by raising the stimulus intensity until the tinnitus was unheard during the stimulus presentation. Second, the level of the stimulus was further increased until the tinnitus was suppressed during the silence interval between the acoustic pulses. This level was called the minimum residual inhibition level (MRIL). The sequential measurement of MML and MRIL from the same stimulus condition offers several advantages such as time efficiency and the ability to compare results between the MRIL and MML. Our study confirms that, from this new approach, MML and MRIL can be easily and quickly obtained from a wide variety of patients displaying either normal hearing or different hearing loss configurations. Indeed, MML was obtained in all patients except one (98.5%), and some level of MRIL was found on 59 patients (86.7%). More so, this approach allows the categorization of tinnitus patients into different subgroups based on the properties of their MRIL.

An Integrative Model Accounting for the Symptom Cluster Triggered After an Acoustic Shock

Acoustic shocks and traumas sometimes result in a cluster of debilitating symptoms, including tinnitus, hyperacusis, ear fullness and tension, dizziness, and pain in and outside the ear. The mechanisms underlying this large variety of symptoms remain elusive. In this article, we elaborate on the hypothesis that the tensor tympani muscle (TTM), the trigeminal nerve (TGN), and the trigeminal cervical complex (TCC) play a central role in generating these symptoms. We argue that TTM overuse (due to the acoustic shock), TTM overload (due to muscle tension), and ultimately, TTM injury (due to hypoxia and "energy crisis") lead to inflammation, thereby activating the TGN, TCC, and cortex. The TCC is a crossroad structure integrating sensory inputs coming from the head-neck complex (including the middle ear) and projecting back to it. The multimodal integration of the TCC may then account for referred pain outside the ear when the middle ear is inflamed and activates the TGN. We believe that our model proposes a synthetic and explanatory framework to explain the phenomena occurring postacoustic shock and potentially also after other nonauditory causes. Indeed, due to the bidirectional properties of the TCC, musculoskeletal disorders in the region of the head-neck complex, including neck injury due to whiplash or temporomandibular disorders, may impact the middle ear, thereby leading to otic symptoms. This previously unavailable model type is experimentally testable and must be taken as a starting point for identifying the mechanisms responsible for this particular subtype of tinnitus and its associated symptoms.

Deuxième niveau de compétence pour l’échographie clinique en médecine d’urgence. Recommandations de la Société française de médecine d’urgence par consensus formalisé

La Société française de médecine d’urgence a élaboré en 2016 des recommandations formalisées d’experts définissant le premier niveau de compétence en échographie clinique en médecine d’urgence. Ce niveau est maintenant complété par un deuxième niveau correspondant à une pratique plus avancée utilisant des techniques non envisagées dans le premier niveau comme l’utilisation du Doppler et nécessitant aussi une pratique et une formation plus poussées. Des champs déjà présents dans le premier référentiel sont complétés, et de nouveaux champs sont envisagés. La méthodologie utilisée est issue de la méthode « Recommandations par consensus formalisé » publiée par la Haute Autorité de santé et de la méthode Delphi pour quantifier l’accord professionnel. Ce choix a été fait devant l’insuffisance de littérature de fort niveau de preuve dans certaines thématiques et de l’existence de controverses. Ce document présente les items jugés appropriés et inappropriés par les cotateurs. Ces recommandations définissent un deuxième niveau de compétence en ECMU.

Study of crystal-field excitations and infrared active phonons in TbMnO3

The Tb³⁺ (4f ⁸) crystal-field (CF) excitations and the infrared phonons in TbMnO₃ are studied as a function of temperature and under an applied magnetic field. The phonon energy shifts reflect local displacement of the oxygen ions that contribute to the CF energy level shifts below 120 K and under magnetic field. The CF polarized transmission spectra provide interesting information about the debated nature of the excitations at 41, 65, 130 cm^-1. We also evaluate the contribution of the charge transfer mechanism to the magnetoelectric process in TbMnO₃ under magnetic field.

Dramatic Increase in Incidence of Ulcerative Colitis and Crohn's Disease (1988-2011): A Population-Based Study of French Adolescents

OBJECTIVES

Few data are available to describe the changes in incidence of pediatric-onset inflammatory bowel disease (IBD). The aim of this study was to describe changes in incidence and phenotypic presentation of pediatric-onset IBD in northern France during a 24-year period.

METHODS

Pediatric-onset IBD (<17 years) was issued from a population-based IBD study in France between 1988 and 2011. Age groups and digestive location were defined according to the Paris classification.

RESULTS

1,350 incident cases were recorded (8.3% of all IBD) including 990 Crohn's disease (CD), 326 ulcerative colitis (UC) and 34 IBD unclassified (IBDU). Median age at diagnosis was similar in CD (14.4 years (Q1=11.8-Q3=16.0)) and UC (14.0 years (11.0-16.0)) and did not change over time. There were significantly more males with CD (females/males=0.82) than UC (females/males=1.25) (P=0.0042). Median time between onset of symptoms and IBD diagnosis was consistently 3 months (1-6). Mean incidence was 4.4/10⁵ for IBD overall (3.2 for CD, 1.1 for UC and 0.1 for IBDU). From 1988-1990 to 2009-2011, a dramatic increase in incidences of both CD and UC were observed in adolescents (10-16 years): for CD from 4.2 to 9.5/10⁵ (+126%; P<0.001) and for UC, from 1.6 to 4.1/10⁵ (+156%; P<0.001). No modification in age or location at diagnosis was observed in either CD or UC.

CONCLUSIONS

In this population-based study, CD and UC incidences increased dramatically in adolescents across a 24-year span, suggesting that one or more strong environmental factors may predispose this population to IBD.

Extra-intestinal Manifestations at Diagnosis in Paediatric- and Elderly-onset Ulcerative Colitis are Associated With a More Severe Disease Outcome: A Population-based Study

BACKGROUND AND AIMS

Data on extra-intestinal manifestations [EIM] and their impact on the disease course of ulcerative colitis [UC] in population-based cohorts are scarce, particularly in paediatric- and elderly-onset UC patients. The aims of this population-based study were to assess: 1] the occurrence of EIM in paediatric- and elderly-onset UC; 2] the factors associated with EIM; and 3] their impact on long-term disease outcome.

METHODS

Paediatric-onset [< 17 years at diagnosis] and elderly-onset UC patients [> 60 years at diagnosis] from a French prospective population-based registry [EPIMAD] were included. Data on EIM and other clinical factors at diagnosis and at maximal follow-up were collected.

RESULTS

In all, 158 paediatric- and 470 elderly-onset patients were included [median age at diagnosis 14.5 and 68.8 years, median follow-up 11.2 and 6.2 years, respectively]. EIM occurred in 8.9% of childhood- and 3% of elderly-onset patients at diagnosis and in 16.7% and 2.2% of individuals during follow-up [p < 0.01], respectively. The most frequent EIM was joint involvement [15.8% of paediatric onset and 2.6% of elderly-onset]. Presence of EIM at diagnosis was associated with more severe disease course [need for immunosuppressants or biologic therapy or colectomy] in both paediatric- and elderly-onset UC (hazard ratio [HR] = 2.0, 95% confidence interval [CI]: 1.0-4.2; and HR = 2.8, 0.9-7.9, respectively). Extensive colitis was another independent risk factor in both age groups.

CONCLUSIONS

Elderly-onset UC patients had lower risk of EIM either at diagnosis or during follow-up than paediatric-onset individuals. EIM at diagnosis predicted more severe disease outcome, including need for immunosuppressive or biologic therapy or surgery, in both paediatric- and elderly-onset UC.

Two genomes of highly polyphagous lepidopteran pests (Spodoptera frugiperda, Noctuidae) with different host-plant ranges

Emergence of polyphagous herbivorous insects entails significant adaptation to recognize, detoxify and digest a variety of host-plants. Despite of its biological and practical importance - since insects eat 20% of crops - no exhaustive analysis of gene repertoires required for adaptations in generalist insect herbivores has previously been performed. The noctuid moth Spodoptera frugiperda ranks as one of the world’s worst agricultural pests. This insect is polyphagous while the majority of other lepidopteran herbivores are specialist. It consists of two morphologically indistinguishable strains (“C” and “R”) that have different host plant ranges. To describe the evolutionary mechanisms that both enable the emergence of polyphagous herbivory and lead to the shift in the host preference, we analyzed whole genome sequences from laboratory and natural populations of both strains. We observed huge expansions of genes associated with chemosensation and detoxification compared with specialist Lepidoptera. These expansions are largely due to tandem duplication, a possible adaptation mechanism enabling polyphagy. Individuals from natural C and R populations show significant genomic differentiation. We found signatures of positive selection in genes involved in chemoreception, detoxification and digestion, and copy number variation in the two latter gene families, suggesting an adaptive role for structural variation.

A Case of Acoustic Shock with Post-trauma Trigeminal-Autonomic Activation

This study reports the case of an acoustic shock injury (ASI), which did not result in a significant hearing loss, but was followed by manifold chronic symptoms both within (tinnitus, otalgia, tingling in the ear, tension in the ear, and red tympanum) and outside the ears (blocked nose, pain in the neck/temporal region). We suggest that these symptoms may result from a loop involving injury to middle ear muscles, peripheral inflammatory processes, activation and sensitization of the trigeminal nerve, the autonomic nervous system, and central feedbacks. The pathophysiology of this ASI is reminiscent of that observed in post-traumatic trigeminal-autonomic cephalalgia. This framework opens new and promising perspectives on the understanding and medical management of ASI.

Auditory Brainstem Responses in Tinnitus: A Review of Who, How, and What?

The auditory brainstem response (ABR) in tinnitus subjects has been extensively investigated over the last decade with the hopes of finding possible abnormalities related to the pathology. Despite this effort, the use of the ABR for tinnitus diagnosis or as an outcome measure is under debate. The present study reviewed published literature on ABR and tinnitus. The authors searched PubMed, MedLine, Embase, PsycINFO, and CINAHL, and identified additional records through manually searching reference lists and gray literature. There were 4,566 articles identified through database searching and 151 additional studies through the manual search (4,717 total): 2,128 articles were removed as duplicates, and 2,567 records did not meet eligibility criteria. From the final 22 articles that were included, ABR results from 1,240 tinnitus subjects and 664 control subjects were compiled and summarized with a focus on three main areas: the participant characteristics, the methodology used, and the outcome measures of amplitude and/or latency of waves I, III, and V. The results indicate a high level of heterogeneity between the studies for all the assessed areas. Amplitude and latency differences between tinnitus and controls were not consistent between studies. Nevertheless, the longer latency and reduced amplitude of wave I for the tinnitus group with normal hearing compared to matched controls was the most consistent finding across studies. These results support the need for greater stratification of the tinnitus population and the importance of a standardized ABR method to make comparisons between studies possible.

Clinical Validation of a New Tinnitus Assessment Technology

Current clinical assessment of tinnitus relies mainly on self-report. Psychoacoustic assessment of tinnitus pitch and loudness are recommended but methods yield variable results. Herein, we investigated the proposition that a previously validated fixed laboratory-based method (Touchscreen) and a newly developed clinically relevant portable prototype (Stand-alone) yield comparable results in the assessment of psychoacoustic tinnitus pitch and loudness. Participants with tinnitus [N = 15, 7 with normal hearing and 8 with hearing loss (HL)] and participants simulating tinnitus (simulators, N = 15) were instructed to rate the likeness of pure tones (250-16 kHz) to their tinnitus pitch and match their loudness using both methods presented in a counterbalanced order. Results indicate that simulators rated their "tinnitus" at lower frequencies and at louder levels (~10 dB) compared to tinnitus participants. Tinnitus subgroups (with vs. without HL) differed in their predominant tinnitus pitch (i.e., lower in the tinnitus with HL subgroups), but not in their loudness matching in decibel SL. Loudness at the predominant pitch was identified as a factor yielding significant sensitivity and specificity in discriminating between the two groups of participants. Importantly, despite differences in the devices' physical presentations, likeness and loudness ratings were globally consistent between the two methods and, moreover, highly reproducible from one method to the other in both groups. All in all, both methods yielded robust tinnitus data in less than 12 min, with the Stand-alone having the advantage of not being dependent of learning effects, being user-friendly, and being adapted to the audiogram of each patient to further reduce testing time.

Raman and infrared study of 4f electron-phonon coupling in HoVO3

First-order Raman scattering and multiphonons are studied in RVO3 (R  =  Ho and Y) as a function of temperature in the orthorhombic and monoclinic phases. Raman spectra of HoVO3 and YVO3 unveil similar features since both compounds have nearly identical R-radii. However, the most important difference lies in the transition temperature involving the V(3+) orbitals, the V(3+) magnetic moments as well as the crystallographic structure. Particularly, the magnetic and orbital reorientations occur at T N2  =  40 K for HoVO3 instead T N2  =77 K in the case of YVO3. For both systems, anomalous phonon shifts which are related to spin-phonon coupling are observed below the V(3+) magnetic ordering temperature (T N1  ≈  110 K) while additional phonon anomalies are exclusively observed in HoVO3 around T (*)  ≈  15 K. On the other hand, infrared (IR) transmittance measurements as a function of temperature reveal Ho(3+5)I8  →  (5)I7 excitations and additional excitations assigned as vibronics. These latter combined with drastic changes in Ho(3+5)I8  →  (5)I7 excitations at T N2, are indicative of a strong coupling between the Ho(3+) ions and the ligand field. This could explain the large magnetocaloric capacity shown by HoVO3.

Lactobacillus bacteremia: Pathogen or prognostic marker?

OBJECTIVE

Lactobacillus bacteremia is a rare event and its epidemiology is poorly known. Whether Lactobacillus bacteremia is a contaminant, a risk factor, or a risk marker of death remains an open question.

PATIENTS AND METHODS

We conducted a retrospective study of patients presenting with Lactobacillus bacteremia (LB), between January 2005 and December 2014, at the Grenoble University Hospital.

RESULTS

LB was observed in 38 patients (0.34% of all positive blood cultures). Cancer (40%), immunosuppression (37%), and use of central venous devices (29%) were frequently associated with LB. We observed a significant increase with time in the number of Lactobacillus positive blood cultures among all blood cultures performed (P=0.04). LBs were divided into two clinical-biological presentations: secondary bacteremia with a known portal of entry (n=30) and isolated bacteremia (n=8). Case fatality was 31% at D28, 55.2% at 1 year in the secondary bacteremia group, and 12.5% (both at D28 and 1 year) in the isolated bacteremia group. Secondary bacteremia with a known portal of entry was significantly associated with case fatality after adjustment for age, co-infection, cancer, immunosuppression, diabetes, and sex (OR 14.9 [1.04-216] P=0.047) for fatality at one year, but not for D28 fatality (P=0.14).

CONCLUSION

Lactobacillus bacteremia may be an important marker of disease severity rather than a pathogen, suggesting comorbidities. It should not be considered a contaminant, but should lead physicians to screen for associated infections and underlying diseases.