Service De Research Articles

Acquired facial atrophy: A neglected clinical sign of POEMS syndrome

I read with great interest the review on POEMS syndrome by Angela Dispenzieri [1]. As indicated by the author, skin lesions are frequent in this syndrome, some characteristic, and considered as minor criteria of POEMS syndrome. These include hyperpigmentation, hypertrichosis, and glomeruloid hemangioma, requiring a whole skin examination. However, the author does not mention acquired facial atrophy observed in more than half of patients in a recent dermatologic series including 21 patients conducted at our institution [2]. This clinical manifestation is similar to the lipoatrophy observed in HIV-infected patients under highly active antiretroviral therapy with protease inhibitors and nucleoside reverse transcriptase inhibitors as a part of the metabolic or lipodystrophy syndrome [3], or in patients with autoimmune diseases and alternate complement pathway abnormalities [4], including lupus panniculitis [5]. In our institution, we consider that POEMS syndrome should be evoked in patients not under antiretroviral treatment presenting with acquired facial lipoatrophy not preceded by a deep skin infiltration as observed in lupus panniculitis, when associated with polyradiculoneuropathy and monoclonal gammopathy. Claude Bachmeyer*, * Service de Médecine Interne, CHU Tenon (AP-HP), 4 rue de la Chine, 75020 Paris, France.

Giant Cell Arteritis as a Cause of Acute Myocarditis in the Elderly

To the Editor: Giant cell arteritis (GCA) is the most common vasculitis in those over age 50 years. The main symptoms are headache, jaw claudication, polymyalgia rheumatica, visual loss, fatigue, and fever. Pericarditis and myocardial infarction due to coronary arteritis have been rarely reported1,2,3. Myopericarditis has been described in only 3 patients1,2. We describe a new case of acute myopericarditis occurring in a patient with previously undiagnosed GCA. An 82-year-old woman was admitted to the emergency department for an acute retrosternal chest pain radiating to both arms and lasting for 30 min. She had no cardiovascular risk factors. She had also had 3 months of fatigue, weight loss, polymyalgia, a bitemporal headache, and jaw claudication. Examination revealed tender temporal arteries. There were no symptoms of chronic or acute heart failure. … Address correspondence to Dr. G. Pugnet, Service de Médecine Interne, CHU Toulouse-Purpan, Place du Docteur Baylac, TSA 40031, 31059 Toulouse cedex, France. E-mail: gpugnet{at}cict.fr

Hidradenitis Suppurativa

To evaluate the expression of innate immunity markers at the site of nodules caused by hidradenitis suppurativa (HS). Prospective analysis of 12 patients with HS. Unité de Cancéro-Dermatologie, Nantes Hospital, Nantes; Service de Dermatologie, Poitiers Hospital, Poitiers; and Service de Dermatologie, Clinique de Courlancy, Reims, France Twelve patients (Hurley stage I or II) in whom the disease had progressed for at least 6 months and who had a minimum of 2 closed nodules in typical sites. Two biopsies were performed at baseline: one in a closed inflammatory nodule and one in healthy adjoining skin. Patients were treated for 3 months with zinc gluconate at a dosage of 90 mg/d. A new biopsy was then performed in the same nodule. Innate immunity markers (toll-like receptors 2, 3, 4, 7, and 9; intercellular adhesion molecule 1; interleukin [IL] 6 and 10; tumor necrosis factor; α melanocyte stimulating hormone; transforming growth factor β; β-defensin 2 and 4; and insulinlike growth factor 1) were studied by immunohistochemical analysis. We observed significantly decreased expression (P < .001) of all the innate immunity markers studied except IL-10 in nonlesional and lesional HS skin. The downregulation of innate markers was significantly stronger in lesional HS skin compared with normal skin except for tumor necrosis factor. Three months of zinc treatment induced a significant increase in the expression of all the markers involved in innate immunity. Our study demonstrates for the first time, to our knowledge, that a deficiency of the main innate immunity markers in typical HS sites may explain the development of chronic inflammatory nodules in this disease.

Renforcer les compétences de parents issus de milieux défavorisés : impacts d’un programme d’entraînement à la résolution de problèmes éducatifs

The difficult economic context of Western countries and sociocultural changes in family structure are increasing the complexity and diversity of parental roles in the accomplishment of everyday tasks. This phenomenon is especially marked in socially and economically disadvantaged areas, which are particularly destabilised by environmental problems. Studies in this field have suggested that parental attitudes and educational practices play a key role in the development of the child. However, these practices remain malleable, and they may oscillate between being risk factors and protective factors. Exploiting this theoretical framework with the goal of reducing the socio-affective and educational risks to children, preventive interventions can be implemented, with the aim of helping parents in their role as educators. The development of parental support programmes, involving efforts to improve parental attitudes and educational practices in a qualitative manner, can thus mediate between disadvantaged socio-economic environment and the behavioural, cognitive and affective development of the child. This article presents exploratory research on this theme, evaluating changes in the attitudes and educational skills of the parents of young children from disadvantaged socio-economic environments following their participation or non-participation in a parental education programme. Fifteen mothers from disadvantaged socio-economic backgrounds took part in a parental education programme entitled “Being the parent of young children” (EPJE; Terrisse and Pithon, 2008), which used a series of cartoons to address the management of educational problems. This group was compared with a control group of 10 mothers from the same socio-economic environment, matched for age and education level. All the families selected received educational assistance at home (AED) or attended clinics (Service de protection maternelle et infantile; PMI) for children under the age of six years. The two groups were evaluated with the Échelle des Compétences Éducatives Parentales (ECEP; the Parental Educative Skills Scale; Terrisse and Larose, 1999), which explores (a) the “rigidity/flexibility”, “wariness/confidence” dimensions of educational attitudes; (b) “normative/elaborative” and “severity/liberalism” aspects of parental behaviour; (c) the feeling of parental “control” according to an “internality/externality” axis. The experimental group was also evaluated to assess the acquisition of knowledge about child education and degree of satisfaction with the programme. We found that the educational attitudes of the mothers in the experimental group changed significantly more towards greater flexibility than those in the control group and, in general, their educational style evolved more favourably than that of the control group (more elaborative practices, more internalised feelings of control). Similarly, the significant difference in results in tests of knowledge before and after the programme reveals an improvement in the identification and appropriation of educational practices by parents. All the mothers of the experimental group declared that their confidence in their ability to manage the difficulties of their child had definitively increased following the programme. This exploratory study demonstrates the beneficial effects of a parental support programme, although the small size of the sample currently precludes the generalisation of these results. Nevertheless, this preliminary study improves our understanding of the processes occurring within these educational groups, the objective being to develop a feeling of competence in parents, by giving them the means to provide an educational structure favouring a better outcome for their child. This research also opens up new possibilities for considering the cultural characteristics of parents from disadvantaged environments, who often come from very different communities.

Response to Letter by Blackburn et al Regarding Article, “Is the Montreal Cognitive Assessment Superior to the Mini-Mental State Examination to Detect Poststroke Cognitive Impairment? A Study With Neuropsychological Evaluation”

HomeStrokeVol. 42, No. 11Response to Letter by Blackburn et al Regarding Article, “Is the Montreal Cognitive Assessment Superior to the Mini-Mental State Examination to Detect Poststroke Cognitive Impairment? A Study With Neuropsychological Evaluation” Free AccessReplyPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReplyPDF/EPUBResponse to Letter by Blackburn et al Regarding Article, “Is the Montreal Cognitive Assessment Superior to the Mini-Mental State Examination to Detect Poststroke Cognitive Impairment? A Study With Neuropsychological Evaluation” Olivier Godefroy, MD, PhD, Jean Marc Bugnicourt, MD and Andreas Fickl, MD Olivier GodefroyOlivier Godefroy Service de Neurologie CHU Nord Amiens, France (Godefroy,Bugnicourt,Fickl) Search for more papers by this author , Jean Marc BugnicourtJean Marc Bugnicourt Service de Neurologie CHU Nord Amiens, France (Godefroy,Bugnicourt,Fickl) Search for more papers by this author and Andreas FicklAndreas Fickl Service de Neurologie CHU Nord Amiens, France (Godefroy,Bugnicourt,Fickl) Search for more papers by this author Originally published22 Sep 2011https://doi.org/10.1161/STROKEAHA.111.630368Stroke. 2011;42:e583Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2011: Previous Version 1 Response:We thank Blackburn et al for their interesting comments on screening tests for poststroke cognitive impairment. Given the frequency and impact of poststroke cognitive impairment, choosing the best possible screening test is important. In view of the MMSE score's poor sensitivity to vascular cognitive impairment and our recent results,1 Blackburn et al suggest that the Montreal Cognitive Assessment (MoCA) should be used instead of the MMSE, with a cutoff ≤23. Although we agree with some of Blackburn et al's points, the currently available evidence (including our own study) does not fully support their position. First, our study supported the moderate sensitivity (0.66) of MMSE when recommended cutoffs are used.1 However, sensitivity improved using cut-off after adjustment of the score for education level (Table 21). Second, Blackburn et al indicate that use of a cutoff ≤23 for the MoCA yielded a sensitivity of 0.84 and a specificity of 0.81 as indicated in Table 3.1 We wish to emphasize that this cut-off does not concern the raw MoCA score, only a specific adjustment of the score for age and education level (Table 31). Third, Blackburn et al indicate that a test with sensitivity and specificity >0.8 meets the criterion for being a good screening tool.The criterion for being an optimal screening test is a critical point. In the article, we provided 2 cut-off values for each test, either to optimize the trade-off between sensitivity and specificity (adjusted MMSE, ≤24; adjusted MoCA, ≤20) or to minimize the false-negative rate (MMSE adjusted, ≤29; MoCA adjusted, ≤26). This allows the reader to choose the test and cut-off according to his/her objective. We agree with the idea that cognitive impairment should be systematically screened for within 6 months of a stroke. Given that the primary objective of stroke care is not the systematic analysis of cognitive and behavioral complaints, the screening tool should minimize the false-negative rate and the likelihood ratio of a negative test (LRN).2 This is achieved after adjustment of the score for age and educational level using our proposed cut-offs for the MMSE (MMSE adjusted, ≤29; false-negative rate, 1 of 62 [ie, 1.6%]; LRN, 0.097) and the MoCA (MoCA adjusted, ≤26; false-negative rate, 3.2%; LRN, 0.06). Conversely, other cut-offs provide higher false-negative rates (MMSE adjusted, ≤24; false-negative rate, 31%; LRN, 0.31; MoCA adjusted, ≤20; false-negative rate, 31%; LRN, 0.36). A high false-negative rate is also observed for the cut-off proposed by Blackburn et al (MoCA adjusted, ≤23; false-negative, 13%; LRN, 0.19). Lastly, the use of a cut-off that minimizes false-negatives would result in cognitive assessment of half the screened patients1 (and not in 80% as suggested by Blackburn et al). The ongoing GRECOG-VASC study (ClinicalTrials.gov identifier: NCT01339195) will provide norms for the MoCA in French-speaking subjects and will examine the ability of these 2 screening tests to predict cognitive impairment at 6 months poststroke.Olivier Godefroy, MD, PhDJean Marc Bugnicourt, MDAndreas Fickl, MD Service de Neurologie CHU Nord Amiens, FranceDisclosuresNone.FootnotesStroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 3 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited. Include a completed copyright transfer agreement form (available online at http://stroke.ahajournals.org and http://submit-stroke.ahajournals.org).

Screening of the sleep respiratory disorders after stroke in a rehabilitation unit

Abstracts / Annals of Physical and Rehabilitation Medicine 54S (2011) e19–e29Conclusion .– Vision is as an evolving field in PRM. We have to explore visionand to become more familiar with problems associated with vision impairment.Patients express visual impairment in terms of functional implications. Visualdeficits can be classified into those that affect acuity and those that affect visualfields.doi:10.1016/j.rehab.2011.07.869CO46-003–EN Screening of the sleep respiratory disorders after stroke ina rehabilitation unit C. Lefevre a , ∗ , L. Stana , M. Jousse b , C. Lucas a , P. Sportouch , N. Bradai ,E. Guettard a , A. Yelnika Service de MPR, universite Paris Diderot, groupe hospitalierSaint-Louis-Lariboisiere F.Widal AP–HP, 200, rue Faubourg Saint-Denis,75010 Paris, France b Service de MPR, hopital Tenon, universite Paris-6, Paris, France ∗ Corresponding author. Keywords: Stroke; Sleep disorders Introduction .– Sleep respiratory disorders SRD (central apnea syndrome orCheynes-Stokes dyspnea) are frequent after stroke (40–70%). The influenceof the SRD on the functional prognosis is debated.

Risk of Highly Resistant Bacteria Importation from Repatriates and Travelers Hospitalized in Foreign Countries: About the French Recommendations to Limit Their Spread

The rapid development of transport and communication, environmental exchanges, and migration of populations creates opportunities for the spread of infectious diseases. The emergence and spread of pathogenic and epidemic pathogens is a major emerging phenomenon of the past 30 years. Some species of bacteria have become resistant to multiple antibiotics and, sometimes, to all antibiotics available: multidrug‐resistant bacteria (MDR), extensively drug‐resistant bacteria (XDR), or pan drug‐resistant bacteria (PDR). 1–3 These terminologies have drawn attention to the evolution of multidrug resistance and the potential difficulties in treating bacterial infections now and in the future. 4 The very high levels of resistance that are currently observed result from massive exposure to antibiotics, to which humans and animals have been subjected over the past 50 years. 5 Resistance to antibiotics concerns not only pathogens but also, and probably even more importantly, the commensally bacteria colonizing individuals (humans and animals). These are less easily detected because the carriage is asymptomatic. More than 80 million foreign visitors travel in France each year. In the same period, 19.4 million French peoples travel to foreign countries, more often in Europe. 6 In addition, 1.4 million French peoples live in foreign countries (i.e., 48% Europe, 20% America, 15% Africa, 8.5% in Asia‐Oceania, and 6.6% in the Near and Middle East). 7 The repatriation of French patients from foreign hospitals, but also health care provided to foreigners traveling in France, whatever their nationality, then expose the French population to highly resistant bacteria acquired in high resistance prevalent areas. The risk of the emergence and spread of highly resistant bacteria from migration has been recently evaluated in France because sporadic or limited epidemic situations have occurred in the recent past with pathogens such as Clostridium difficile ribotype 027, 8,9 carbapenemase‐producing Enterobacteriaceae (CPE), 10–12 vancomycin‐resistant Enterococcus (VRE), 13,14 or multidrug‐resistant Acinetobacter … Corresponding Author: Didier Lepelletier, MD, PhD, Unite de Gestion du Risque Infectieux ‐ Service de Bacteriologie‐Hygiene, Centre Hospitalier Universitaire de Nantes, F‐44093 Nantes Cedex 01, France. E‐mail: didier.lepelletier{at}chu-nantes.fr

Burden and outcome of HIV infection and other morbidities in health care workers attending an Occupational Health Program at the Provincial Hospital of Tete, Mozambique

To investigate the burden and outcome of HIV infection and other morbidities amongst a Mozambican hospital staff. Within an occupational health service set up in April 2008 in the provincial hospital of Tete, Mozambique, we offered to all staff members an initial clinical, laboratory and radiological screening and followed them up prospectively until April 2010. A total of 47.5% of 423 health workers attended the program. The cohort (female-to-male ratio: 2.2; mean age: 39 years) consisted mostly of auxiliary staff (43%) and nurses (29.8%). At initial screening, 71% were asymptomatic. HIV infection (28.4%) and tuberculosis (TB) (21%) were the main reported antecedent illnesses. Laboratory screening revealed anaemia (haemoglobin level <10 mg/dl) in 9% participants, abnormal liver enzymes in 23.9% and a reactive non-treponemal syphilis test in 5%. Of 145 performed chest X-rays, 13% showed abnormalities. All 113 health workers not recently tested for HIV were screened, and 31 were newly diagnosed with HIV infection (resulting in an overall HIV prevalence of 43.8%). Nine cases of TB were diagnosed at screening/during follow-up. In April 2010, all but one of the participants were alive. All HIV-infected health workers under antiretroviral therapy were actively followed-up. Serious conditions were frequently diagnosed in health workers, in particular HIV infection. Mid-term outcome was favourable within this program. Creation of screening and care services dedicated to caregivers should be of highest priority in similar African settings.

Severe neonatal hypercalcemia related to maternal exposure to nutritional supplement containing Spirulina

Spirulina platensis (Norst.) Geitler is a microalgae widely harvested in Asia, Africa and South America and used for centuries in these countries as a natural medicine and a nutritional complement. Indeed, this cyanobacterium could exert antioxidant, anti-inflammatory, anti-infective, hypolipidemic and anticancer properties [1–3]. It could also represent a nutritional supplement in developing countries, as it contains important quantities of proteins, minerals, B complex and liposoluble vitamins, particularly vitamin D [1]. In developed countries, nutritional supplements containing S. platensis are increasingly used and sold over the counter. They represent a “natural”, “ethnic” and “obviously safe”medication. Pregnant women are particularly exposed to these supplements. We here report a case of severe neonatal hypercalcemia related to an excessive maternal exposure to S. platensis. In April, 2010, a neonate was hospitalised the first day of his live in our university hospital for generalised seizures. His parents had no medical antecedent, there was no consanguinity, pregnancy was normal and the neonate was eutrophic with no malformation. Serum calcium was increased to 3.10 mmol/L (normal 10 ng/ml) and calcitriol (1,25dihydroxycholecalciferol) was greatly increased (260 pg/ml, normal 18–60 pg/ml). In the mother’s serum, 25hydroxycholecalciferol was normal (28 ng/ml) but calcitriol was increased (125 pg/ml, i.e. twice normal). Questioning revealed exposure to vitamin D supplementation at the beginning of pregnancy, and then daily exposure to S. platensis from the fourth month of pregnancy. S. platensisrelated maternal intoxication with 25-hydroxycholecalciferol hydroxylated to calcitriol by the placental 1α-hydroxylase is suspected to be responsible for foetal hypercalcemia. Causality assessment was scored “likely” according to the World Health Organisation Uppsala Monitoring Centre (WHO-UMC) criteria [4]. The safety of nutritional supplements containing S. platensis is poorly evaluated. The supplements seem to contain low levels of algal toxins, particularly microcystins (hepatotoxins), but S. platensis decreases in vitro hepatocyte viability [5]. Anatoxins (neurotoxins) have been detected in some S. platensis preparations [6]. No human S. platensis-induced hepatitis or neurological disease has been reported to our knowledge. Sparse S. platensis-related G. Moulis (*) :A. Batz :G. Durrieu : J.-L. Montastruc Service de Pharmacologie Clinique, Faculte de Medecine, Centre Midi-Pyrenees de Pharmacovigilance, de Pharmacoepidemiologie et d’Informations sur le Medicament, Unite INSERM U 1027, Centre Hospitalier Universitaire de Toulouse, Universite de Toulouse, 37 Allees Jules-Guesde, 31000 Toulouse, France e-mail: gmoulis@hotmail.com

Sacred Music from the Era of Louis XIII

SACRED MUSIC FROM THE ERA OF LOUIS XIII Gantez. Missa Lae tamini. Serie proposee par Michel Cuvelier. (Cahiers de musique. Patrimoine musical bourguignon.) (Patrimoine musical francais. Collection choeur.) Versailles: Centre de Musique Baroque de Versailles, 2009. [Notes biographiques, etc., p. [3-5]; score, p. 7-26. ISMN M560161709, ISBN-13/EAN 9790560161709, pub. no. CAH 170. euro12] Artus Aux-Cousteaux. Magnificat primi toni (1641); Magnificat secundi toni (1641); Magnificat tertii toni (1641); Magnificat quarti toni (1641); Magnificat quinti toni (1641); Magnificat sexti toni (1641); Magnificat septimi toni (1641); Magnificat octavi toni (1641). Edition proposee par Gerard Geay. Restitution du plain-chant: Jean-Yves Hameline. 8 volumes. (Patrimoine musical francais. Collection choeur.) Versailles: Centre de Musique Baroque de Versailles, 2009. [Notes biographiques, etc., p. [3-6]; scores, p. 7-12 or 13. ISMN M560161815, ISBN-13/EAN 9790560161815, pub. no. CAH 181 (primi toni); ISMN M560161822, ISBN-13/EAN 0790560161822, pub. no. CAH 182 (secundi toni); ISMN M560161839, ISBN-13/EAN 9790560161839, pub. no. CAH 183 (tertii toni); ISMN M560161846, ISBN-13/EAN 9790560161846, pub. no. CAH 184 (quarti toni); ISMN M560161853, ISBN-13/EAN 0790560161853, pub. no. CAH 185 (quinti toni); ISMN M560161860, ISBN-13/EAN 0790560161860, pub. no. CAH 186 (sexti toni); ISMN M560161877, ISBN-13/EAN 0790560161877, pub. no. CAH 187 (septimi toni); ISMN M560161884, ISBN-13/EAN 0790560161884, pub. no. CAH 188 (octavi toni). Each volume euro9.50] This group of publications by the Centre de Musique Baroque de Versailles (CMBV) contributes both to the study and to the performance of sacred music from the time of Louis XIII, a period for which sacred music has not received much scholarly attention until recently. The year 2009 brought two important additions to the collection that is published under the CMBV's Cahiers de musique series, including Gantez's (1607-ca. 1668) Missa Lae tamini, and a cycle of Magnificats on the eight Psalm tones by Artus Aux- Cousteaux (ca. 1590-ca. 1654) issued in eight separate volumes. These scores complement earlier publications of works of Antoine Boesset (1586-1643), and Guillaume Bouzignac (ca. 1587-after 1642) in the CMBV Cahiers de musique series, as well as a newly issued large collection of Boesset's sacred works edited by Peter Bennett and published by A-R Editions (Sacred Music, Recent Researches in the Music of the Baroque Era, 164-65 [Middle - ton, WI: A-R Editions, 2010]) all adding substantially to the modest list of modern editions available to the scholar and musician for French sacred music from the early seventeenth century. The nine scores under consideration here contain music for four unaccompanied voices, offering a rich new body of unexplored choral music for collegiate choirs. Gantez is known to us primarily through his 1643 book L'entretien des mu - siciens (The care of musicians), a delightfully entertaining and informative collection of letters that sheds light on the customs and practices of musicians associated with the maItrises (choir schools) of seventeenth-century France. Recent research has established for the first time Gantez's birth in Marseille in 1607 (Florence Chappee, Annibal Gantez, auteur de L'entretien des musiciens (1643), in MaItrises & chapelles aux XVIIe & XVIIIe siecles: Des institutions musicales au service de dieu, ed. Bernard Dompnier, 271-89, Collection Histoires croisees [Clermont- Ferrand: Presses Uni versitaires Blaise- Pascal, 2003]), and also has given evidence that he served at least seventeen maItrises during his peripatetic career, several of them for more than one period of employment. Gantez worked as far south as Toulon and as far north as Le Havre, and served St. Paul and St. Innocents in Paris in the three years before his move to Auxerre in 1643 where he published his book. No manuscripts of this composer have survived, but in 1642 Ballard published two of Gantez's masses, one of which was the Missa Lae tamini (Mass of Rejoicing). …

Melatonin for sleep-disturbed children with autism spectrum disorders: can we really speak of a substitution treatment?

Dear Editor, In a recent article of this journal, Doyen et al. [2] provided a narrative review of melatonin use for sleep-disturbed children with autism spectrum disorders. In this very comprehensive work, the authors usefully summarized the pharmacokinetics of melatonin and its physiopathology in autism spectrum disorders, and discussed clinical trials in this population. In their very complete selection of publications, Doyen et al. considered 17 articles, from single case reports to randomized controlled trials. It must be noted, however, that eight of these studies mainly involved children with non-autistic neurodevelopmental disabilities (without providing subgroup analyses), or concerned children with Rett syndrome, a genetic disease whose affiliation to the autism spectrum is much questioned nowadays [1], and in which sleep problems generally differ from those seen in autism [5]. For these reasons, in a recent systematic review on the same topic, we limited our documentary sources to 12 of these 17 citations [4]. However, despite these discrepancies in the selection of literature, we came to the same conclusions than Doyen et al. that, although not evidencebased for now (considering the small number of randomized controlled trials and their methodological limits), melatonin treatment for sleep problems in individuals with autism spectrum disorders has received very encouraging results. We also agreed with Doyen et al. that more studies are needed, particularly for the collection of long-term follow-up data [3]. In Doyen et al.’s article, the section which is devoted to the analysis of clinical trials is entitled ‘‘Melatonin substitution in autistic subjects with sleep disturbance’’ (our emphasis), and we now would like to focus our comment on whether melatonin treatment in this context really is a substitution or not. First, it must be noticed that, whereas melatonin deficiency has been repeatedly reported in individuals with autism spectrum disorders, its association with sleep disturbance in this population has never been demonstrated for now. Second, within all the trials reviewed by Doyen et al.—and if we put aside Rett syndrome—no patient with an autism spectrum condition had a documented melatonin deficiency. Finally, 11 of these 17 studies included melatonin doses escalation up to 5 mg per day and more, which—as indicated by Doyen et al. later in their paper—lead to melatonin blood levels incommensurable to the physiological ones. For all these reasons, we believe that melatonin use in sleep-disturbed individuals with autism spectrum disorders cannot yet be considered as a substitution treatment. In fact, as Doyen et al. wrote in their discussion, the mechanisms by which melatonin improves sleep in many individuals with autism spectrum disorders remain unknown. Although some authors have hypothesized that these beneficial effects may proceed from the chronobiotic properties of melatonin, this hypothesis has not been proven for now and some arguments suggest that hypnotic effects may be involved (like for example the fact that the clinical benefits of melatonin are often seen from the first day of treatment). Indeed, it is well demonstrated that F. Guenole J.-M. Baleyte CHU de Caen, Service de psychiatrie de l’enfant et de l’adolescent, 14000 Caen, France

Detachment as a corporate ethic

This article examines efforts by De Beers, the world’s largest supplier of rough diamonds, to better regulate the conditions under which its stones are cut and polished across a global network of buyers, contractors, and subcontractors. Drawing on ethnographic fieldwork at an offshore processing unit in South India that was built to service De Beers’ buyers, this article explores how ethical accounting regimes are materialized on the floor of a global factory and how they are grounded in an industrial bureaucracy. In a global supply chain like this one, I argue, codes of practice and audit checklists demand to be understood as material technologies that afford companies and individuals new purchase on an ethic of detachment.

Letter by Lacout et al Regarding Article, “Prevalence, Characteristics, and Outcomes of Patients Presenting With Cardiogenic Unilateral Pulmonary Edema”

HomeCirculationVol. 123, No. 20Letter by Lacout et al Regarding Article, “Prevalence, Characteristics, and Outcomes of Patients Presenting With Cardiogenic Unilateral Pulmonary Edema” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Lacout et al Regarding Article, “Prevalence, Characteristics, and Outcomes of Patients Presenting With Cardiogenic Unilateral Pulmonary Edema” Alexis Lacout Pierre Yves Marcy Triet Ngo Alexis LacoutAlexis Lacout Centre d'imagerie Médicale Centre Médico Chirurgical Aurillac, France (Lacout) Search for more papers by this author Pierre Yves MarcyPierre Yves Marcy Head & Neck and Interventional Radiology Department Antoine Lacassagne Cancer Research Institute Nice, France (Marcy) Search for more papers by this author Triet NgoTriet Ngo Service de Pneumologie Hôpital Ambroise Paré (APHP) Boulogne-Billancourt, France Search for more papers by this author Originally published24 May 2011https://doi.org/10.1161/CIRCULATIONAHA.110.005082Circulation. 2011;123:e607To the Editor:It is with great interest that we read the article by Attias et al, “Prevalence, Characteristics, and Outcomes of Patients Presenting With Cardiogenic Unilateral Pulmonary Edema,” which appeared in the September 14, 2010 issue of Circulation.1 We wish to congratulate the authors, and would like to make some comments.This interesting retrospective study regarding the incidence and pathogenesis of unilateral pulmonary embolism included 869 consecutive patients presenting with heart failure and pulmonary edema. Prevalence of unilateral pulmonary embolism was 2.1%, and mitral regurgitation was observed in every single case.Allow us to put forward that, according to this comprehensive series, pulmonary embolism was never observed in emergency units, despite its high prevalence. Patients were evaluated solely on the basis of chest radiographs and transthoracic echocardiography. We would like to point out the interest in the use of computed tomography scans in intensive care units for patients presenting with heart failure. In appropriately selected patients, the pulmonary arteries, as well as aorta and coronary arteries, may be efficiently examined in a triple–rule-out high-quality computed tomography angiography examination.2 In fact, heart failure with pulmonary edema may be observed in patients with acute severe pulmonary embolism, and hence be related to pulmonary hypertension.3,4 As a result, pulmonary edema in territories not involved by vascular thrombosis may occur secondary to increased compensatory circulation and hyperperfusion with fluid overload. Indeed, severe unilateral obstruction of either the right or left main pulmonary artery may lead to hypoperfusion of the involved lung and to hyperperfusion with unilateral pulmonary embolism of the contralateral lung.3,4 Therefore, we believe that in patients presenting with heart failure and unilateral pulmonary embolism, severe asymmetric pulmonary embolism should be evoked, even more so in the absence of mitral regurgitation. A CT scan may be required, and should be performed cautiously because of iodinated contrast medium injection, which may increase blood volume and hence pulmonary edema.Another point to consider is unilateral pulmonary embolism that may be observed contralateral to anomalous pulmonary venous drainage. CT angiography may also contribute in highlighting such a congenital anomaly.5Alexis Lacout, MD Centre d'imagerie Médicale Centre Médico Chirurgical Aurillac, FrancePierre Yves Marcy, MD Head & Neck and Interventional Radiology Department Antoine Lacassagne Cancer Research Institute Nice, FranceTriet Ngo, MD Service de Pneumologie Hôpital Ambroise Paré (APHP) Boulogne-Billancourt, FranceAcknowledgmentsWe thank Claudia Schlager for her help and suggestions on this letter.DisclosuresNone.

Conception et évaluation d’une intervention brève « alimentation et prévention cardiovasculaire » en médecine de premier recours

L’objectif était d’évaluer la faisabilité d’une intervention brève (IB) « alimentation et prévention cardiovasculaire » par des médecins généralistes d’un service de médecine de premier recours. Ont été mesurés : la proportion des patients atteints, la durée et les étapes de l’IB effectuées, les obstacles, l’utilité et la pertinence de l’IB perçus, les connaissances et changements projetés des patients. En un mois, 76 patients parmi 99 éligibles (77 %) ont participé à l’étude et 48 ont reçu l’IB. Trois des cinq étapes de l’IB étaient pratiquées dans 38 % des cas. L’IB était perçue comme importante par les cinq médecins qui se disaient confiants et motivés. Le manque de temps était l’obstacle principal à la mise en œuvre de l’IB. À l’issue de l’IB, 77 % des patients disaient avoir appris quelque chose, 64 % prévoyaient des changements et 98 % pensaient que c’était le rôle du médecin de discuter leur alimentation. Malgré tout, l’implantation de l’IB dans la routine de fonctionnement des praticiens est difficile. The goal of our project was to assess acceptability and feasibility of a 5-step brief intervention (BI) on diet and coronary heart disease (CHD) prevention by general practitioners in a primary care setting. The intervention process and its acceptability by patients and physicians were assessed by standardised interviews and questionnaires, measuring the proportion of patients included, BI duration, perceived obstacles, usefulness and relevance of BI, patients’ knowledge and planned behavior change. Of 99 eligible patients, 76 (77 %) participated and 48 received the BI, which took 5–10 minutes in the consultation. Three of the five steps were usually (38 %) performed. The five physicians were interested and motivated but mentioned lack of time. Most patients (77 %) said they had learned something new about their diet in relation to CHD, and 64 % were able to express at least one dietary habit they planned to change. Ninety-eight percent considered it was their physician's role to discuss their diet to prevent CHD. However, BI's implementation proves difficult in physicians’ routine.

Let the pediatric intensive care unitʼs door open: But not to all winds!*

Hopital Bicetre, Service de Reanimation Pediatrique Polyvalente; Le Kremlin-Bicetre, France (Devictor) The author has not disclosed any potential conflicts of interest.

Letter by Pierot Regarding Article “Flow-Diverter Stent for the Endovascular Treatment of Intracranial Aneurysms: A Prospective Study in 29 Patients With 34 Aneurysms”

To the Editor: We read with great interest the results of a prospective study regarding the use of a flow-diverter stent for endovascular treatment of intracranial aneurysms.1 Twenty-nine patients with 34 complex aneurysms were treated. Treatment failed in 3 patients (10.3%). As in previous series, the rate of perioperative clinical complications was low, but because of delayed complications, the mortality and morbidity rates were 4% and 15%, respectively. This series described the initial experience of 3 centers with a completely new device during the ascending phase of the learning curve. Therefore, it is probably not appropriate to make definitive conclusions with such a limited and preliminary experience. Flow diversion is a new endovascular approach dedicated to the treatment of complex aneurysm types: large and giant, fusiform, and wide-neck aneurysms. For some of these lesions, no alternative treatment is available. Surprisingly, in the Lubicz et al1 series, the number of small aneurysms treated with flow diverters is quite high (aneurysms with diameters <10 mm: 18/34 patients …

Letter by Baruteau et al Regarding Article, “Peripartum Cardiomyopathy as a Part of Familial Dilated Cardiomyopathy”

HomeCirculationVol. 123, No. 2Letter by Baruteau et al Regarding Article, “Peripartum Cardiomyopathy as a Part of Familial Dilated Cardiomyopathy” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Baruteau et al Regarding Article, “Peripartum Cardiomyopathy as a Part of Familial Dilated Cardiomyopathy” Alban-Elouen Baruteau, MD, Erwan Donal, MD, PhD and Jean-Claude Daubert, MD, PhD Alban-Elouen BaruteauAlban-Elouen Baruteau CHU RennesService de Cardiologie et Maladies VasculairesUniversité de Rennes 1Rennes, France (Baruteau, Donal, Daubert) Search for more papers by this author , Erwan DonalErwan Donal CHU RennesService de Cardiologie et Maladies VasculairesUniversité de Rennes 1Rennes, France (Baruteau, Donal, Daubert) Search for more papers by this author and Jean-Claude DaubertJean-Claude Daubert CHU RennesService de Cardiologie et Maladies VasculairesUniversité de Rennes 1Rennes, France (Baruteau, Donal, Daubert) Search for more papers by this author Originally published18 Jan 2011https://doi.org/10.1161/CIRCULATIONAHA.110.971978Circulation. 2011;123:e8We have read with great interest the article by van Spaendonck-Zwarts et al, which strongly suggests that a subset of peripartum cardiomyopathy (PPCM) is part of the spectrum of familial dilated cardiomyopathy.1 Entering PPCM in the field of familial dilated cardiomyopathy strongly modifies thinking on PPCM pathogenesis and management. We respectfully disagree in accepting the authors' interpretations of study findings. To our mind, they underestimate the clinical implication of their results and recommend overly restrictive indications for familial echocardiographic screening, which led us to write this letter.In the first systematic approach examining the familiality and genetics of PPCM, they found that cardiological screening of first-degree relatives of 3 PPCM patients who did not show full recovery revealed unknown dilated cardiomyopathy in all 3 families. Unfortunately, they decided not to perform such a familial screening in the 7 PPCM patients who experienced a complete normalization of left ventricular size and function. They also recommend “presymptomatic cardiological screening for covert dilated cardiomyopathy in first-degree family members of PPCM patients without recovery of left ventricular function and dimensions.”1Familial occurrence of PPCM was suggested in the literature by 6 previous anecdotal cases reporting a total of 8 kinships with more than 1 member affected by PPCM.1–3 Catastrophic outcomes were reported in 5 of these 6 publications with no recovery, death or heart transplantation for intractable heart failure in PPCM patients.However, this is not consistent with our experience, and our case report was the only one assessing a familial occurrence in 2 sisters who experienced severe PPCM with a favorable outcome and a full recovery.3 Both sisters presented dilated cardiomyopathy in the peripartum period with severe systolic dysfunction (left ventricular ejection fraction respectively 20% and 40%). They were aggressively supported in a timely manner, including inotropic support and extracorporeal membrane oxygenation for 1 of them and long-term medical treatment including a β-blocker agent and angiotensin-converting enzyme inhibitor. Full recovery was assessed by cardiac magnetic resonance imaging and transthoracic echocardiography, respectively, at 12- and 3-month follow-ups.In the current era of heart failure management, PPCM prognosis appears to be better than previously reported, with a left ventricular function normalization rate of 54%.4 Our observation shows that full recovery does not authorize elimination of a familial covert dilated cardiomyopathy.Therefore we suggest that cardiological screening be recommended to all first-degree relatives of PPCM patients, regardless of gender, even in the case of normalization of left ventricular size and function. It should allow presymptomatic diagnosis of unknown familial dilated cardiomyopathy in relatives. Despite the fact that it was recommended 10 years ago by the National Institutes of Health on PPCM,5 the impact of such a screening strategy remains to be assessed in large-scale studies.Alban-Elouen Baruteau, MDErwan Donal, MD, PhDJean-Claude Daubert, MD, PhD CHU Rennes Service de Cardiologie et Maladies Vasculaires Université de Rennes 1 Rennes, FranceDisclosuresNone.

HLA-G: a look back, a look forward.

HLA-G is best known as a nonclassical HLA Class I molecule of low polymorphism with an expression restricted to fetal tissues at the maternal-fetal interface. This is true, but there is so much more... The first function to be characterized for HLA-G was that of the inhibition of decidual (maternal) NK cell cytolysis by HLA-G-expressing fetal cytotrophoblast cells [1]. These findings were the basis for a substantial proportion of the HLA-G research because they proved that the expression of HLA-G by a cell, in this case a trophoblast cell, protected it from destruction by killers of the immune system, in this case NK cells. Further studies showed that HLA-G played a crucial role in the tolerance of the fetus by its mother, i.e., in the maternal-fetal tolerance, which is the only example of physiological tolerance to semi-allogeneic tissues. From this point, HLA-G was named ‘‘tolerogenic,’’ and a precise characterization of HLA-G, its tolerogenic properties, and its clinical uses was sought. The review by Rizzo et al. summarizes the key findings concerning HLA-G and pregnancy and particularly focuses on (1) HLA-G expression throughout embryo development, starting from the embryonic stem cells, (2) the structural diversity of HLA-G and the methods used to detect its structures, and (3) the clinical uses that can be or are already made of HLA-G detection in the context of pregnancy. Rejection is a strong immune defense-like mechanism that involves multiple cell subsets, including NK cells, T cells, B cells, and antigen-presenting cells. Therefore, to counter rejection, tolerance mechanisms have to be at least as complex as and must target all rejection mechanisms and effectors. Studies have revealed that HLA-G inhibitory functions are broad and target multiple immune cell subsets, acting directly or indirectly on effector cell subsets. Indeed, it has been shown that HLA-G inhibits the cytolytic functions of NK cells [1], the antigen-specific cytolytic functions of CD8 T cells [2], the allo-proliferative responses of CD4 T cells [3], and the differentiation of dendritic cells [4]. Furthermore, HLA-G is capable of stopping the ongoing proliferation of T cell and NK cells [5, 6].These results proved that HLA-G is capable of directly acting on all actors of an immune response such as a graft rejection or an anti-tumoral response. Recent results showed that in addition to a direct inhibition of cell function, HLA-G had less direct, but possibly deeper functions through the generation of suppressor/regulatory cells [7]. These results imply that HLA-G may participate in the general re-shaping of the immune system to ignore specific antigens, a mechanism also called specific tolerance. The immunological functions and the mechanisms of action of HLA-G, including a particular focus on HLA-Grelated regulatory cells, are detailed in the review by Carosella et al. Nonimmunological functions have also been reported for HLA-G, and this review also focuses on its role in hematopoiesis. HLA molecules are highly polymorphic, and it is well known that associations exist between particular alleles and disease. Studies on HLA-G polymorphism were amongst the first to be performed after the gene was discovered [8] E. D. Carosella (&) J. LeMaoult CEA, I2BM, Service de Recherches en Hemato-Immunologie, 75475 Paris, France e-mail: Edgardo.Carosella@cea.fr

Josef Hoffmann's unknown masterpiece: the garden of Stoclet House in Brussels (1905–1911)

Art is art, and life is life, but to live life artistically: that is the art of life. Peter Altenberg 1 In June 2009 Stoclet House complete with its furnishings and its garden was declared part of ...

The relationship between elderly suicide rates and telephone use: a cross-national study

Social isolation is an important determinant of elderly suicides (Shah and De, 1998). If elderly people have telephones then social isolation can be reduced as they can contact friends and relatives and vice versa. Also, the elderly can use the telephone to seek help from telephone helplines, general practitioners, social workers, psychiatric services and friends and relatives. Additionally, general practitioners, social workers, psychiatric services and friends and relatives can contact elderly people to check on them and support them. However, a major criticism of such interventions is that those determined to kill themselves are unlikely to use a helpline. There are several studies looking at the relationship between suicide and telephone help lines. These studies showed evidence that the helpline reduced suicidality during the course of the telephone consultation or immediately afterwards and reduced the number of re-attempted suicides (De Leo et al., 1995; Mishara and Daigle, 1997; Vaiva et al., 2006; Gould et al., 2007). A study of elderly participants reported an association between lower suicide rates and availability of a telephone help and telephone check service (De Leo et al., 1995). This service provided elderly people with home assistance by allowing them to call for help and to receive weekly assessments of needs and emotional support. However, there are only a limited number of studies in this area. Therefore, a cross-national study examining the relationship between elderly suicide rates and the prevalence of societal use of telephone was undertaken.