Oral versus intravenous high-dose methylprednisolone for treatment of relapses in patients with multiple sclerosis (COPOUSEP)

International audienceSummaryBackground High doses of intravenous methylprednisolone are recommended to treat relapses in patients with multiple sclerosis, but can be inconvenient and expensive. We aimed to assess whether oral administration of high-dose methylprednisolone was non-inferior to intravenous administration. Methods We did this multicentre, double-blind, randomised, controlled, non-inferiority trial at 13 centres for multiple sclerosis in France. We enrolled patients aged 18–55 years with relapsing-remitting multiple sclerosis who reported a relapse within the previous 15 days that caused an increase of at least one point in one or more scores on the Kurtzke Functional System Scale. With use of a computer-generated randomisation list and in blocks of four, we randomly assigned (1:1) patients to either oral or intravenous methylprednisolone, 1000 mg, once a day for 3 days. Patients, treating physicians and nurses, and data and outcome assessors were all masked to treatment allocation, which was achieved with the use of saline solution and placebo capsules. The primary endpoint was the proportion of patients who had improved by day 28 (decrease of at least one point in most affected score on Kurtzke Functional System Scale), without need for retreatment with corticosteroids, in the per-protocol population. The trial was powered to assess non-inferiority of oral compared with intravenous methylprednisolone with a predetermined non-inferiority margin of 15%. This trial is registered with ClinicalTrials.gov, number NCT00984984. Findings Between Jan 29, 2008, and June 14, 2013, we screened 200 patients and enrolled 199. We randomly assigned 100 patients to oral methylprednisolone and 99 patients to intravenous methylprednisolone with a mean time from relapse onset to treatment of 7·0 days (SD 3·6) and 7·4 days (3·9), respectively. In the per-protocol population, 66 (81%) of 82 patients in the oral group and 72 (80%) of 90 patients in the intravenous group achieved the primary endpoint (absolute treatment difference 0·5%, 90% CI −9·5 to 10·4). Rates of adverse events were similar, but insomnia was more frequently reported in the oral group (77 [77%]) than in the intravenous group (63 [64%]). Interpretation Oral administration of high-dose methylprednisolone for 3 days was not inferior to intravenous administration for improvement of disability scores 1 month after treatment and had a similar safety profile. This finding could have implications for access to treatment, patient comfort, and cost, but indication should always be properly considered by clinicians. Funding French Health Ministry, Ligue Française contre la SEP, Tev

Anxiety and Psycho-Physiological Stress Response to Competitive Sport Exercise

Introduction: Sport is recognized as beneficial for health. In certain situation of practice, it nevertheless appears likely to induce a stress response. Anxiety is a stress response-modulating factor. Our objective is to characterize the role of anxiety in the stress response induced by a selective physical exercise.Method: Sixty-three young male military conducted a selective sporting running event (a 8-km commando-walk) and were recorded the day before, the day of the race, and the day after. The variables were psychometric [personality questionnaires, coping and anxious/stress state, and physiological (nocturnal heart rate variability and actigraphy)]. The subjects were classified, using scores on anxiety questionnaires at baseline, into two groups according to their anxious (G ANX) or non-anxious (G N-ANX).Results: Before the race, the G ANX was characterized by a lower level of self-esteem, higher scores in dysfunctional coping and a greater perceived stress compared to the G N-ANX. Compared to G N-ANX, the stress response to the exercise was higher in G ANX: G ANX exhibited (Selye, 1950) in immediate post-exercise, greater level in activation markers, and mental fatigue associated with a same level of physical fatigue and (Kim et al., 2018) in nocturnal post-exercise, an increase in sympathetic activation associated with a higher sleep fragmentation.Conclusion: A competition selection sport exercise causes a stress response, particularly for anxious subjects. Anxious status could be involved in the risk of emergence of overtraining in sport practice. These results must be taken into account when sport practice is used for anxiety management

L'histoire de l'Hôpital militaire de Nouméa (1855-1958) (essai sur les fondemants de la médecine coloniale)

A travers l'histoire de l'hôpital militaire de Nouméa fondé en 1855 et géré par le Service de Santé des Armées jusqu'en 1958, il s'agit ici d'un essai sur les fondements de la médecine coloniale . Au delà des idées convenues qui perdurent au niveau des archétypes et peuvent nourrir la polémique, le projet consistait à mener une étude historique par une interaction pluridisciplinaire à la manière de Fernand Braudel pour qui la vie est l'école de l'histoire . L'anthropologie collabore largement à la méthodologie par le biais d'un comparatisme maîtrisé. Il convenait donc d'inclure le cadre spatio-temporel incluant les idées dominantes de l'époque, afin de discerner ce qui anima au sens étymologique les personnels de santé des colonies dans une aventure à la fois humaine et humanitaire ; ce néologisme révélateur apparut au XIXème et fut appliqué au domaine médical, dès 1858, par le chirurgien major Vinson. Dans l'histoire, l'évolution d'une institution permet ainsi d'expliquer mais aussi de percevoir le sens vers lequel elle se dirige, selon la pensée de Durkheim. En cela, Gaston Bourret médecin chef du laboratoire de l'hôpital colonial de Nouméa, mort en service le 24 avril 1917, peut apparaître comme un des précurseurs des French Doctors .BREST-BU Médecine-Odontologie (290192102) / SudocPARIS-Bib. Serv.Santé Armées (751055204) / SudocSudocFranceF

Le coup de chaleur d'exercice (à propos de 33 cas)

Le coup de chaleur d'exercice (CCE) ou exertional heat stroke se définit comme une élévation extrême de la température centrale au cours d'un travail musculaire intense et prolongé, qui s'accompagne de manifestations neurologiques, d'une altération des métabolismes cellulaires et d'une souffrance ischémique des grandes fonctions, pouvant aboutir au syndrome de défaillance multiviscérale. L'auteur nous présente une étude rétrospective de 33 cas de coups de CCE survenus chez des militaires d'unités stationnées en Bretagne. Après la description du CCE, de son épidémiologie et de ses hypothèses physiopathologiques l'auteur rapporte puis discute les résultats de l'étude en les confrontant aux données de la littérature. Il présente notamment l'ensemble des facteurs favorisants et les mesures préventives correspondantes. L'auteur expose notamment, concernant la genèse du CCE, l'importance des conditions environnementales et notamment de l'hygrométrie, l'influence relative de la température ambiante et le rôle de la motivation et du stress. Il souligne le rôle du système immuno-inflammatoire et la défaillance du système nerveux central qui aboutit à ce tableau d'encéphalopathie d'effort. Il conclut enfin sur les perspectives de recherche et d'amélioration de la prise en charge concernant cette pathologie.BREST-BU Médecine-Odontologie (290192102) / SudocPARIS-Bib. Serv.Santé Armées (751055204) / SudocSudocFranceF

Exercise efficiency impairment in metabolic myopathies

International audienc

Anxiety and Psycho-Physiological Stress Response to Competitive Sport Exercise

International audienceIntroduction: Sport is recognized as beneficial for health. In certain situation of practice, it nevertheless appears likely to induce a stress response. Anxiety is a stress response-modulating factor. Our objective is to characterize the role of anxiety in the stress response induced by a selective physical exercise.Method: Sixty-three young male military conducted a selective sporting running event (a 8-km commando-walk) and were recorded the day before, the day of the race, and the day after. The variables were psychometric [personality questionnaires, coping and anxious/stress state, and physiological (nocturnal heart rate variability and actigraphy)]. The subjects were classified, using scores on anxiety questionnaires at baseline, into two groups according to their anxious (G ANX) or non-anxious (G N-ANX).Results: Before the race, the G ANX was characterized by a lower level of self-esteem, higher scores in dysfunctional coping and a greater perceived stress compared to the G N-ANX. Compared to G N-ANX, the stress response to the exercise was higher in G ANX: G ANX exhibited (Selye, 1950) in immediate post-exercise, greater level in activation markers, and mental fatigue associated with a same level of physical fatigue and (Kim et al., 2018) in nocturnal post-exercise, an increase in sympathetic activation associated with a higher sleep fragmentation.Conclusion: A competition selection sport exercise causes a stress response, particularly for anxious subjects. Anxious status could be involved in the risk of emergence of overtraining in sport practice. These results must be taken into account when sport practice is used for anxiety management

The ratio of maximal handgrip force and maximal cycloergometry power as a diagnostic tool to screen for metabolic myopathies

International audienceMetabolic myopathies comprise a diverse group of inborn errors of intermediary metabolism affecting skeletal muscle, and often present clinically as an inability to perform normal exercise. Our aim was to use the maximal mechanical performances achieved during two functional tests, isometric handgrip test and cycloergometer, to identify metabolic myopathies among patients consulting for exercise-induced myalgia. Eighty-three patients with exercise-induced myalgia and intolerance were evaluated, with twenty-three of them having a metabolic myopathy (McArdle, n = 9; complete myoadenylate deaminase deficiency, n = 10; respiratory chain deficiency, n = 4) and sixty patients with non-metabolic myalgia. In all patients, maximal power (MP) was determined during a progressive exercise test on a cycloergometer and maximal voluntary contraction force (MVC) was assessed using a handgrip dynamometer. The ratio between percent-predicted values for MVC and MP was calculated for each subject (MVC%pred:MP%pred ratio). In patients with metabolic myopathy, the MVC%pred:MP%pred ratio was significantly higher compared to non-metabolic myalgia (1.54 ± 0.62 vs. 0.92 ± 0.25; p < 0.0001). ROC analysis of MVC%pred:MP%pred ratio showed AUC of 0.843 (0.758-0.927, 95% CI) for differentiating metabolic myopathies against non-metabolic myalgia. The optimum cutoff was taken as 1.30 (se = 69.6%, sp = 96.7%), with a corresponding diagnostic odd ratio of 66.3 (12.5-350.7, 95% CI). For a pretest probability of 15% in our tertiary reference center, the posttest probability for metabolic myopathy is 78.6% when MVC%pred:MP%pred ratio is above 1.3. In conclusion, the MVC%pred:MP%pred ratio is appropriate as a screening test to distinguish metabolic myopathies from non-metabolic myalgia

A Collet–Sicard syndrome due to internal carotid artery dissection associated with cerebral amyloid angiopathy–related inflammation

Background: Cerebral amyloid angiopathy–related inflammation is a rare condition with approximately 100 reported cases. Its clinical manifestations are varied. We report here a novel presentation of this disease. Case presentation: A 61-year-old Caucasian man presented with rapidly progressive paralysis of the IX, X, XI and XII right cranial nerves associated with right central facial nerve palsy. Brain computed tomography angiography and cerebral catheter angiography found a focal fusiform enlargement of the distal cervical portion of the right internal carotid artery, related to a pseudo-aneurysm suggesting an evolution of a dissection and intra-cranial vessel dysplasia. Brain magnetic resonance imaging showed multiple asymmetrical subcortical regions of hyperintensity on T2 fluid-attenuated inversion recovery sequences. Punctiform cortical hyposignals on T2-weighted gradient echo magnetic resonance imaging sequences were mostly congruent with the white matter hyperintensities. There was a decreased cerebral perfusion at the frontal hyperintense fluid-attenuated inversion recovery region. Spectrometry identified a lactate–lipid peak. A brain biopsy showed intravascular amyloid deposits. Corticosteroid therapy was initiated, leading to a dramatic improvement of both clinical condition and magnetic resonance imaging brain lesions. Conclusion: This case report suggests that extra-cranial vasculitis and dysplasia can exceptionally be found in patients satisfying cerebral amyloid angiopathy–related inflammation criteria

[Systematic implementation of transthoracic echocardiography, transesophageal echocardiography and 24-hour Holter ECG for the detection of cardiac sources of embolism in patients with stroke or transient ischemic attack. A retrospective study of 220 patients.]

International audienceINTRODUCTION: Embolism of cardiac origin accounts for around 20% of ischemic strokes. ECG and transthoracic echocardiography (TTE) are commonly obtained during the evaluation of patient of ischemic stroke but specific indications for the transesophageal (TEE) echocardiography and 24-hour Holter ECG (Holter) remain uncertain. OBJECTIVES: The aim of this study is to report the contribution of TTE, TEE and Holter performed as a routine during the evaluation of patients with ischemic stroke (IS) or transient ischemic attack (TIA). METHODS: This is a retrospective single-center study of 220 patients hospitalized between 1st January 2007 and 31st December 2010 for a first IS or TIA. RESULTS: One hundred and forty-three IS and 77 TIA are identified. The average age of patients was 66 years (18-88 years). TTE/TEE/24-hour Holter allowed the diagnosis of cardiac sources of embolism in 135 patents (61.3%). TTE/TEE identified potential source of cardiogenic embolism in 126 patients (52.2%). Twenty four-hour Holter ECG tracked supraventricular arrhythmia in 15 patients (6.7%), 9 (4%) which had non-contributory ultrasound assessment. CONCLUSION: The systematic implementation of TTE/TEE/Holter is useful for identifying potential sources of cardiogenic embolism. The performance of TEE remains above the TTE. Holter should be recommended because it is a cost effective and non-invasive tool