Patrick Dehail

Cognitive disorders in HIV-infected patients: are they HIV-related?

Objectives:Large unselected studies on representative samples of HIV-infected patients with a whole battery of neuropsychological tests and cerebral MRI scan are required to assess the frequency of neurocognitive impairment (NCI), the determinants of mild neurocognitive disorders (MNDs), or HIV-associated dementia (HAD) and the relationship between NCI and MRI scan findings. Methods:Investigation of 400 consecutively enrolled HIV-1-infected adults from the ANRS CO3 Aquitaine Cohort, using standardized neurocognitive tests chosen to achieve consistency with Frascatis criteria. Half of the patients had a cerebral MRI scan allowing gray and white matter volume measurement. Factors associated with NCI were studied by logistic regression models. Results:Median age of participants was 47 years, 79% were male and 89% received combination antiretroviral treatment (cART), of whom 93% had plasma HIV RNA below 500 copies/ml. Median CD4 cell count was 515 cells/&mgr;l. Prevalence of NCI was 59%, including 21% of asymptomatic NCI, 31% of MND, and 7% of HAD. A low level of education, prior neurologic AIDS-defining disorders event, anxiety, depressive symptoms, and prior history of brain damage were independently associated with MND or HAD, but neither HIV nor cART-related variables. The presence of NCI was significantly associated with lower gray matter fraction. Interpretation:In this large unselected cohort, a high prevalence of symptomatic neurocognitive disorders was mainly related to its traditional determinants and associated with gray matter atrophy at early stages of the disease.

High frequency of poor locomotor performance in HIV-infected patients.

Objectives:To provide up-to-date assessments of locomotor function in HIV-infected patients and to identify potential determinants of impaired function. Design:Cross-sectional study in 324 HIV-1-infected adults from the French Agency for AIDS and Hepatitis Research (ANRS) CO3 Aquitaine Cohort using standardized locomotor tests. Methods:Patients underwent standardized testing assessing balance, walking ability, functional capacity and lower limb muscle performance. Poor test performance was defined by cut-offs based on age-specific data of the general population. Factors associated with poor test performance were studied by logistic regression. Results:Median age was 48 years, 80% were men and 89% were on antiretroviral treatment. The most frequently altered locomotor test was the five-times sit-to-stand (5STS) test, assessing lower limb muscle performance (poor performance: 53%). In multivariable analysis, time since HIV diagnosis was associated with poor 5STS performance [odds ratio (OR) = 1.08 per year; 95% confidence interval (CI): 1.03, 1.13]. In patients below 30 years, elevated BMI was associated with higher likelihood of good performance (OR = 0.81 per kg/m2; 95% CI: 0.69, 0.93), whereas in those above 70 years this association was reversed (OR = 1.30 per kg/m2; 95% CI: 1.10, 1.53; P < 10−3 for interaction). We found no association with antiretroviral treatment. Conclusion:One of two adults with controlled HIV infection had poor lower limb muscle performance, which might put this population at risk of falls and fracture. The 5STS test is a simple test that should be recommended to assess muscular performance in HIV care.

Quantification of reaction forces during sitting pivot transfers performed by individuals with spinal cord injury.

OBJECTIVES To quantify the reaction forces exerted under the hands, feet and buttocks when individuals with spinal cord injury performed sitting pivot transfers. DESIGN Twelve men with paraplegia completed 3 transfers between seats of the same height (0.5 m high) and 3 transfers to a high target seat (0.6 m high). RESULTS Greater mean and peak vertical reaction forces were always recorded under the hands compared with the feet (p<0.001) during the transfers. Mean vertical reaction forces were similar between the leading and trailing hands (p>0.088) for the 2 transfers studied. However, the mean vertical reaction force underneath the leading hand was greater when transferring between a seat of the same height compared with one of a higher height (p=0.021) and vice-versa for the trailing hand (p=0.0001). The peak vertical reaction force always occurred earlier (p<0.0001) and was greater underneath the trailing hand compared with the leading one (p<0.02), and reached its highest value when transferring to the high target seat (p=0.003). Peak and mean horizontal reaction forces were always higher underneath the trailing hand compared with the leading hand (p<0.001). CONCLUSION These results provide evidence-based data to better understand transfers and strengthen clinical practice guidelines targeting the preservation of upper extremity integrity.

One-Year Incidence of Hyperosmolar States and Prognosis in a Geriatric Acute Care Unit

Background: Hyperosmolar syndromes are associated with high mortality rates, yet little is known about their incidence and their prognosis. Objective: To determine the 1-year incidence of hyperosmolar states and the prognostic factors for in-hospital and 1-year mortality. Method: A 6-month prospective cohort study was conducted in a 40-bed acute care geriatric unit and included all patients who developed plasma osmolarity of 320 mosm/l or greater. Age, sex and known cognitive impairment as possible risk factors of hyperosmolarity were assessed. In-hospital and 1-year mortality were calculated and risk factors for death among baseline patient characteristics were sought. Results: 48 (11) of the 436 inpatients in the study were identified as hyperosmolar. Diabetic hyperosmolarity was found in 8 patients. Cognitive impairment was a risk factor for hyperosmolarity (relative risk 2.39, 95% confidence interval 2.18–3.33, p < 0.001), but not age or sex. Infections were accompanied by hyperosmolarity in 30 (62.5). Thirty-five patients (72.9) were bed- or chair-ridden. In-hospital mortality was higher in hyperosmolar patients (35.4) than in the others (16.7%, p = 0.003). Causes of death were infection in 5 (29.4), terminal cachexia in 5, thrombosis in 3, gastric bleeding in 1, renal failure in 2 and heart failure in 1. Functional dependency for mobility was a risk factor for in-hospital mortality but not the degree of hyperosmolarity. One-year mortality was 68.7%. Functional dependency and pressure ulcers were independent predictors of 1-year mortality (p = 0.005 and p = 0.044, respectively). Conclusion: Hyperosmolar states occurred in cognitively impaired and dependent patients and resulted in high mortality rates at short and at mid-term. Mortality was related to functional dependency rather than to hyperosmolarity.

Ejaculatory stimulation, quality of semen and reproductive aspects in spinal cord injured men.

This is a retrospective study of 39 male spinal cord injured patients who, over the last 5 years, have consulted us for ejaculatory dysfunction or infertility. All of these patients underwent at least two distinct sessions during which attempts were made to induce an ejaculation by vibratory stimulation, electric stimulation, or by using subcutaneous physostigmine. A semen analysis was performed each time that an ejaculate was obtained. By one or more of these techniques, 75% of these subjects were able to ejaculate. The level of the neurological lesion had a significant influence on the success rate. Likewise, the mode employed to produce an ejaculation influenced certain characteristics of the sperm collected (mean volume, percentage of motile forms), the best results being obtained by vibratory stimulation. Among the 10 couples who had consulted us for medically assisted reproduction, three pregnancies were obtained, two of which resulted in the birth of healthy children. Although the techniques of stimulation that we use allow ejaculation, the possibilities of reproduction remain limited in particular because of the difficulty in obtaining semen of adequate quality. Nevertheless, recent methods of micromanipulation of gametes should considerably improve the prognosis of the seminal insufficiencies in men with spinal cord injury.

Maximal and sustained isokinetic lower-limb muscle strength in hospitalized older people

Maximal strength decreases with aging whereas sustained strength is less affected. Strength decline may be worsened by hospitalization. The aim of this study was to estimate the maximal and sustained isokinetic muscle strength of lower limbs in hospitalized elderly subjects. We evaluated 43 hospitalized elderly subjects (86 ± 5 years), 28 elderly community‐dwelling control subjects (75.4 ± 6.2 years), and 25 young subjects (28.2 ± 3.7 years). Among hospitalized subjects, 30 underwent isokinetic evaluation at clinical stability (T0) and again 1 month later (T1). Maximal peak torque (MPT) of the plantarflexors was measured at 30° and 60°/s, and knee flexors and extensors at 90°/s. Evolution of the MPT and the endurance coefficient (EC) on 20 repetitions of plantarflexion at 60°/s were calculated. MPT of plantarflexors and knee flexors and extensors had improved at T1 compared with T0, in hospitalized subjects. MPT evolution and EC values during the sustained strength test revealed no decrease in strength over time in hospitalized subjects at T0 and at T1 compared with community‐dwelling control subjects and young subjects. In hospitalized subjects, the absence of an initial phase of fast decrease in muscle strength, which is observed in young subjects during the sustained strength test, could explain this result. It could be related to the modifications of muscle‐fiber composition described in elderly subjects and enhanced by hospitalization. Muscle Nerve, 2007

Individualized Cognition‐Action intervention to prevent behavioral disturbances and functional decline in institutionalized older adults: a randomized pilot trial

To evaluate the effectiveness of an individualized Cognition‐Action (CA) intervention to reduce behavioral disturbances in severely deconditioned institutionalized old adults.

aSSeSSMeNt oF PoStURaL INStaBILItY IN PatIeNtS wIth tRaUMatIc BRaIN INJURY UPoN eNRoLMeNt IN a VocatIoNaL aDJUStMeNt PRoGRaMMe

OBJECTIVE To assess postural instability in patients with traumatic brain injury upon enrolment to vocational adjustment. DESIGN A cross-sectional study. PATIENTS AND METHODS Sixty-eight patients at the time of admission to a vocational adjustment programme and 52 healthy age-matched controls were evaluated. Complaints of dizziness, or balance impairment and data from a clinical examination were recorded. Postural characteristics during quiet upright standing were assessed using a static posturographic platform. RESULTS Twenty-six patients complained of dizziness or instability and 36 had evidence of neurological impairment. Centre of pressure displacement and area were significantly increased in the traumatic brain injury group as a whole, compared with controls, even among 23 patients who had no complaint or clinical abnormality. CONCLUSION In spite of a high variability in time since injury, significant posturographic abnormalities were found in patients with traumatic brain injury, including those who had no complaints or evidence of neurological impairment. Posturography may help in understanding how a traumatic brain injury impairs the human balance, and may provide helpful information for patients participating in vocational adjustment programmes, especially when jobs require a long standing posture or balance.

Safety and self-reported efficacy of botulinum toxin for adult spasticity in current clinical practice: a prospective observational study

Objective: To determine the safety and the self-reported efficacy of botulinum toxin injections for adult spasticity in current clinical practice. Design: A prospective observational study. Subjects: A total of 406 adult patients with focal spasticity received of 1136 series botulinum toxin injections at Bordeaux University Hospital from January 2007 to December 2009. Methods: Adverse events following botulinum toxin injections were reported. Their severity and the therapeutic efficacy of botulinum toxin injections were estimated with a four-point self-reporting scale (0 to 3). Latency and duration of adverse events and subjective improvement were also noted. Results: The data of 640 series of injections were analyzed. Forty-six (7.2%) adverse events were reported, of which 36 (78%) were local. There were 18 (39%) cases of local muscular weakness with an average duration of 30.0 (SD 38.2) days, and an average severity score of 1.0 (SD 0.97). Among systemic adverse events, there were 8 (17%) cases of excessive fatigue without global muscular weakness and 2 (4%) cases of transitory generalized muscular weakness. The average subjective improvement score was 1.89 (SD 0.97) and was higher for upper, than for lower, limbs (P=0.007). Conclusion: Self-reported adverse events following botulinum toxin injections in spasticity are rare, often benign and of short duration in current clinical practice. Botulinum toxin is considered effective by patients in treating spasticity of the upper and lower limbs.

Prise de décision et fonctions exécutives chez le patient atteint de traumatisme crânien grave : validation d’une tâche de prise de décision et facteurs corrélatifs

OBJECTIVE: At the chronic stage, severe traumatic brain injured (TBI) patients experience difficulty in making decisions. Several studies have demonstrated the involvement of the prefrontal cortex, in particular the orbitofrontal region, in decision-making. The aim of the present study was to validate a decision-making task in this population and to ascertain whether the components of their dysexecutive syndrome may affect their decision-making and lead to difficulties for social rehabilitation. PATIENTS AND METHODS: Fifteen TBI patients and 15 controlled subjects matched for age, sex and years of education were assessed by a battery of executive tests (GREFEX) and by the gambling task (GT). RESULTS: The TBI subjects performed significantly worse than the controlled group in five out of six GREFEX tests. The TBI choices are significantly more disadvantageous than the choices of the control group when considering the three last blocks of 20 cards of the GT. The GT total score correlated significantly with execution time of the Stroop interference condition and the Trail Making Task B, as well as with the two measures (correct sequence span and number of crossed boxes) of the double condition of Baddeleys task. CONCLUSION: We postulate that executive functioning (supervisory attentional system) influence performance in the gambling task through mechanisms of inhibitory control, divided attention and working memory. Thus, this task seems to be determined by multiple factors; the process of decision-making may depend on frontal integrity.