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Magy L.,Limoges University Hospital Center
Revue de Medecine Interne | Year: 2017

Diagnosing a peripheral neuropathy is sometimes challenging, as the causes are diverse and the clinical pictures heterogeneous. Overall, diagnosing a patient with peripheral neuropathy will require some knowledge in almost every field of medicine. Therefore, it appears crucial to adopt a diagnostic strategy that is based on solid clinical and neurophysiological grounds. The present paper describes a three-step diagnostic strategy: (1) to delineate a clinico-pathologic entity from clinical and electrodiagnostic findings; (2) to propose a list of plausible causes based on step one, history and clinical context; (3) to use appropriate workup in order to determine the cause or mechanism of the neuropathy. The three steps of this diagnostic strategy necessitate a high level of expertise and interaction between physicians is highly desirable. Finally, an aggressive course and a severe impairment should lead to relentlessly look for a curable cause. © 2017 Société Nationale Française de Médecine Interne (SNFMI).


Robert-Gangneux F.,University of Rennes 1 | Darde M.-L.,University of Limoges | Darde M.-L.,French Institute of Health and Medical Research | Darde M.-L.,Limoges University Hospital Center
Clinical Microbiology Reviews | Year: 2012

The apicomplexan parasite Toxoplasma gondii was discovered a little over 100 years ago, but knowledge of its biological life cycle and its medical importance has grown in the last 40 years. This obligate intracellular parasite was identified early as a pathogen responsible for congenital infection, but its clinical expression and the importance of reactivations of infections in immunocompromised patients were recognized later, in the era of organ transplantation and HIV infection. Recent knowledge of host cell-parasite interactions and of parasite virulence has brought new insights into the comprehension of the pathophysiology of infection. In this review, we focus on epidemiological and diagnostic aspects, putting them in perspective with current knowledge of parasite genotypes. In particular, we provide critical information on diagnostic methods according to the patient's background and discuss the implementation of screening tools for congenital toxoplasmosis according to health policies. © 2012, American Society for Microbiology. All Rights Reserved.


Vallat J.-M.,Limoges University Hospital Center | Mathis S.,University of Limoges | Funalot B.,University of Poitiers
Current Opinion in Neurology | Year: 2013

PURPOSE OF REVIEW: This review focuses on recent advances in the diagnostic approaches and the underlying pathophysiological mechanisms of Charcot-Marie-Tooth (CMT) disease. We also discuss the emerging therapies for this hereditary neuropathy. RECENT FINDINGS: To date, numerous genes are implicated in CMT, and new genes have recently been found to be associated with this neuropathy (INF2, FBLN5, etc.). Some specific or evocative clinical signs of CMT subtypes (proteinuria with INF2 mutations, etc.) have been identified. Characteristic pathological findings, which may suggest gene mutations, are also recognized by nerve biopsy (mainly ultrastructural lesions). SUMMARY: CMT disease is the most common inherited neuromuscular disorder, with a fairly homogeneous clinical phenotype (progressive distal muscle weakness and atrophy, foot deformities, distal sensory loss, and depressed tendon reflexes). With more than 40 genes implicated, an update of the present and rather confusing classification of CMT is needed. Over the last few years, new mutated genes have been discovered. Although nerve biopsy is not routinely carried out in CMT neuropathies, it may show characteristic features, which can orientate the search for the mutated gene. There are currently no effective medications for CMT, but clinical trials are ongoing or planned. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Vallat J.-M.,Limoges University Hospital Center | Sommer C.,University of Würzburg | Magy L.,Limoges University Hospital Center
The Lancet Neurology | Year: 2010

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic neuropathy of supposed immune origin. Understanding of its pathophysiology has recently improved, although its causes remain unclear. The classic presentation of CIDP includes sensory and motor symptoms in the distal and proximal segments of the four limbs with areflexia, evolving over more than 8 weeks. Raised protein concentrations in CSF and heterogeneous slowing of nerve conduction are typical of the condition. In addition to this usual phenotype, distribution of symptoms, disease course, and disability can be heterogeneous, leading to underdiagnosis of the disorder. Diagnosis is sometimes challenging and can require use of imaging and nerve biopsy. Steroids and intravenous immunoglobulin are effective, and plasma exchange can be helpful as rescue therapy. The usefulness of immunosuppressants needs to be established. The identification of specific diagnostic markers and new therapeutic strategies with conventional or targeted immunotherapy are needed to improve the outlook for patients with CIDP. © 2010 Elsevier Ltd. All rights reserved.


Patient-reported outcome measures are being developed for more relevant assessments of pain management. The patient acceptable symptom state (PASS) ("feeling well") and the minimal clinically important improvement (MCII) ("feeling better") have been determined in clinical trials, but not in daily pain management. We carried out a national multicenter cohort study of patients over the age of 50 years with painful knee osteoarthritis (KOA) or hip osteoarthritis (HOA) who had visited their general practitioner and required treatment for more than 7 days. Overall, 2414 patients (50.2% men, mean age 67.3 years, body mass index 27.9 kg/m2, 33.5% with HOA) were enrolled by 1116 general practitioners. After 7 days of treatment, PASS was estimated on a numerical rating scale as 4 at rest and 5 on movement, for both HOA and KOA, above the PASS threshold in clinical trials. In KOA, PASS was more frequently reached in men and younger people with less pain at rest and on movement, and in patients specifically seeking an improvement during sport activities. In HOA, PASS was most frequently reached in patients with low levels of pain at risk and in nonobese patients. MCII was -1 numerical rating scale point after 7 days of usual treatment. This improvement is smaller than that recorded in randomized controlled trials, and was the same for both sites, both at rest and on movement. In conclusion, patient-reported outcome values in daily practice differ from those in clinical trials, and their determinant factors may depend on the site of osteoarthritis. Assessments of the treatment of painful osteoarthritis should be adapted to the characteristics and daily life of the patient, to personalize patient management. © 2012 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.


Bouteille B.,Limoges University Hospital Center
Medecine et Sante Tropicales | Year: 2014

Within the genus Taenia, three species are human parasites: T. solium, T. saginata and a new uncommon species, T. asiatica, described recently in Asia. T. saginata and T. solium live as adult tapeworms in human intestines, where they cause taeniasis. T. saginata is widely present worldwide, in all regions where cattle are bred. T. solium is endemic in many countries where livestock and consumption of pigs are common. Cattle and pigs become infected by ingesting eggs emitted by humans into the environment and serve as the respective intermediate hosts of these helminths and host larval forms, or metacestodes or cysticerci. Cysticerci develop into adult worms in the human intestines after a person has eaten contaminated raw or undercooked meat. In the T. solium, eggs are also human contaminants. Humans, like swine, can develop cysticercosis after ingesting eggs with water or contaminated food, or via dirty hands. The clinical manifestations of cysticercosis are highly variable both in kind and in severity. The period between initial infection and the onset of symptoms can also vary. The clinical expression of cysticercosis is generally dependent on the number, size and location of the cysts, as well as the host immune response to the parasite. The preferred locations are the muscles, subcutaneous tissues, central nervous system (CNS), and eyes. Subcutaneous and muscular forms are often asymptomatic. Severe cysticercosis is due to larvae located in human CNS — neurocysticercosis. The World Health Organization (WHO) lists neurocys-ticercosis as a neglected tropical disease. It estimates that about 50 million people worldwide have neurocysticercosis in the world and that it causes about 50,000 deaths each year. Its most frequent clinical manifestations are seizures, intra-cranial hypertension, neurological deficits, and sometimes psychiatric manifestations. It is also responsible for more than 50% of the cases of late-onset epilepsy in developing countries. The T. solium taeniasis/cysticercosis complex is endemic in many developing countries in sub-Saharan Africa, Latin America, and Asia. Although T. solium had virtually disappeared in developed countries due to industrialization, improved methods of husbandry, and health checks, cysticercosis and neurocysticercosis are diagnosed anew in North America, Europe and Australia due to increased immigration from endemic areas. Cysti-cercosis is considered an eradicable disease. Although theoretically feasible, this concept has been replaced by projects to control and reduce the impact of cysticercosis on human health (through mass treatment of people, veterinary control of pigs, improved farming techniques, and health education). © 2014, John Libbey Eurotext. All rights reserved.


Marquet P.,Limoges University Hospital Center
Methods in Molecular Biology | Year: 2012

This chapter reviews recent applications of mass spectrometry to systematic toxicological analysis (STA), where extended lists of compounds of toxicological interest are screened, as well as to the general unknown screening (GUS), where all exogenous compounds present in a sample are tentatively detected and identified, without any preselection. Many recent improvements in sample preparation, chromatographic separation, gas chromatography-mass spectrometry, and above all liquid chromatography-mass spectrometry techniques are described, which are applicable or have been applied to STA and/or GUS, generally with promising results. These improvements come from miniaturization and automation of solid-phase extraction, turbulent-flow or ultrahigh-pressure liquid chromatography, linear ion traps, accurate (e.g., time of flight or orbital trap) mass spectrometry, as well as software refinements to alternate between different ionization modes or automatically interpret the results. It also shows that robust LC-MS/MS techniques already exist for STA or GUS, which are at least as efficient as the traditional techniques used in most toxicology laboratories, such as GC-MS or high-performance liquid chromatography with diode-array detection, as shown by three comparative studies. However, the major drawback of LC-MS/MS in the full-scan mode for STA or GUS is that it still lacks universal reference libraries due to insufficient reproducibility of LC-MS(/MS) mass spectra obtained with different instrument types. © 2012 Springer Science+Business Media, LLC.


Christou N.,Limoges University Hospital Center
Journal of visceral surgery | Year: 2013

The two most common early complications of thyroid surgery are hypocalcemia (20-30%) and recurrent laryngeal nerve injury (5-11%). Bilateral recurrent nerve paralysis resulting in adduction of the vocal cords is a rare life-threatening complication (occurring in less than 0.1% of cases that requires emergency management. Prevention of complications depends on careful operative technique and is enhanced for some teams by the use of specific techniques such as intraoperative neuromonitoring. Postsurgical hypocalcemia is managed by the administration of calcium plus vitamin D for at least 10 days. Recurrent laryngeal nerve paralysis recovers in most cases, and no invasive therapy should be performed for at least six months, except for emergency presentations; laryngeal surgery techniques may offer significant improvement if phonation or respiratory sequelae persist beyond six months, but the results are inconsistent. There should be a systematic strategy for detection of complications after thyroidectomy involving a multidisciplinary approach. Copyright © 2013. Published by Elsevier Masson SAS.


OBJECTIVE:: The objective of this study was to determine the efficacy of alginate staple-line reinforcement of fissure openings as compared with stapling alone, with or without tissue sealant or glue, in reducing the incidence and duration of air leakage after pulmonary lobectomy for malignancy. SUMMARY BACKGROUND DATA:: No randomized trial evaluating alginate staple-line reinforcement has been performed to date. METHODS:: The Staple-line Reinforcement for Prevention of Pulmonary Air Leakage study was a multicenter randomized trial, with blinded evaluation of endpoints. Patients over 18 years of age scheduled for elective open lobectomy or bilobectomy for malignancy were eligible for enrollment. At thoracotomy, patients were deemed ineligible if an unanticipated pneumonectomy was indicated, or if air leakage occurred after the liberation of pleural adhesions. Otherwise, if the fissure was incomplete or the lung had an emphysematous appearance, patients were randomized to either standard management or interventional procedure consisting of fissure opening with linear cutting staplers buttressed with paired alginate sleeves (FOREseal). The number of eligible patients necessary in each randomization arm was estimated to be 190, and an outcomes analysis was performed on an intention-to-treat basis. RESULTS:: Of the 611 patients consented to study enrollment, 380 met the inclusion criteria and were randomized. Based on an intention-to-treat analysis, the primary endpoint of air leak duration was not different between the 2 groups: 1 day (range: 0–2 d) in the FOREseal group and 1 day (range: 0–3 d) in the control group (P = 0.8357). In addition, the 2 groups were similar in terms of the proportion of patients presenting with prolonged air leakage (7.8% in the FOREseal group vs 11.3% in the control group, P = 0.264) and the average duration of chest drainage (P = 0.107). Procedure costs were comparable for both groups. CONCLUSIONS:: FOREseal did not demonstrate a significant advantage over standard treatment alone. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.


OBJECTIVES:: The aim of this study was to compare nasojejunal early enteral nutrition (NJEEN) with total parenteral nutrition (TPN), after pancreaticoduodenectomy (PD), in terms of postoperative complications. BACKGROUND:: Current nutritional guidelines recommend the use of enteral over parenteral nutrition in patients undergoing gastrointestinal surgery. However, the NJEEN remains controversial in patients undergoing PD. METHODS:: Multicenter, randomized, controlled trial was conducted between 2011 and 2014. Nine centers in France analyzed 204 patients undergoing PD to NJEEN (n = 103) or TPN (n = 101). Primary outcome was the rate of postoperative complications according to Clavien-Dindo classification. Successful NJEEN was defined as insertion of a nasojejunal feeding tube, delivering at least 50% of nutritional needs on PoD 5, and no TPN for more than consecutive 48?hours. RESULTS:: Postoperative complications occurred in 77.5% [95% confidence interval (95% CI) 68.1–85.1] patients in the NJEEN group versus 64.4% (95% CI 54.2–73.6) in TPN group (P = 0.040). NJEEN was associated with higher frequency of postoperative pancreatic fistula (POPF) (48.1% vs 27.7%, P = 0.012) and higher severity (grade B/C 29.4% vs 13.9%; P = 0.007). There was no significant difference in the incidence of post-pancreatectomy hemorrhage, delayed gastric emptying, infectious complications, the grade of postoperative complications, and the length of postoperative stay. A successful NJEEN was achieved in 63% patients. In TPN group, average energy intake was significantly higher (P < 0.001) and patients had an earlier recovery of oral feeding (P = 0.0009). CONCLUSIONS:: In patients undergoing PD, NJEEN was associated with an increased overall postoperative complications rate. The frequency and the severity of POPF were also significantly increased after NJEEN. In terms of safety and feasibility, NJEEN should not be recommended. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

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