Severe colchicine poisoning treated successfully with kidney replacement therapy and plasmapheresis: a case report.

Colchicine is commonly prescribed for treatment of inflammatory conditions but has a narrow therapeutic window and dangerous toxicity profile. Here we describe a case of survival after massive unintentional colchicine overdose treated with plasmapheresis and renal replacement therapy. A 37 year old male with history of pericarditis presented to the Emergency Department with a chief complaint of nausea, vomiting, and diarrhea after unintentionally ingesting 36 mg of colchicine 17 h prior to arrival. An initial colchicine concentration resulted at 5.1 ng/mL (30 h post-ingestion) and peaked at 12 ng/mL (40 h post-ingestion). He was treated with continuous kidney replacement therapy (CKRT) beginning on his first day of hospitalization and with plasmapheresis on hospital days two through four. The patient's course was complicated by multiorgan failure including coagulopathy, respiratory failure, neuropathy, renal failure, pancytopenia, and heart failure. He was discharged to inpatient rehabilitation on hospital day 24. On clinical follow up four months after discharge the patient was found to have no significant persistent morbidity related to colchicine overdose.

Delta radiomics analysis of Magnetic Resonance guided radiotherapy imaging data can enable treatment response prediction in pancreatic cancer.

BACKGROUND: Magnetic Resonance Image guided Stereotactic body radiotherapy (MRgRT) is an emerging technology that is increasingly used in treatment of visceral cancers, such as pancreatic adenocarcinoma (PDAC). Given the variable response rates and short progression times of PDAC, there is an unmet clinical need for a method to assess early RT response that may allow better prescription personalization. We hypothesize that quantitative image feature analysis (radiomics) of the longitudinal MR scans acquired before and during MRgRT may be used to extract information related to early treatment response. METHODS: Histogram and texture radiomic features (n = 73) were extracted from the Gross Tumor Volume (GTV) in 0.35T MRgRT scans of 26 locally advanced and borderline resectable PDAC patients treated with 50 Gy RT in 5 fractions. Feature ratios between first (F1) and last (F5) fraction scan were correlated with progression free survival (PFS). Feature stability was assessed through region of interest (ROI) perturbation. RESULTS: Linear normalization of image intensity to median kidney value showed improved reproducibility of feature quantification. Histogram skewness change during treatment showed significant association with PFS (p = 0.005, HR = 2.75), offering a potential predictive biomarker of RT response. Stability analyses revealed a wide distribution of feature sensitivities to ROI delineation and was able to identify features that were robust to variability in contouring. CONCLUSIONS: This study presents a proof-of-concept for the use of quantitative image analysis in MRgRT for treatment response prediction and providing an analysis pipeline that can be utilized in future MRgRT radiomic studies.

Influence of the level of arterial resection on the replanting and revascularization results in hand surgery: prospective study over 22 months.

The objective of this work was to assess whether the injury mechanisms are responsible for histological arterial lesions. This prospective single-center study included adults with wrist or hand arterial injury. Arterial resection of at least 2 mm from the proximal and distal stumps was performed before the arterial anastomosis. Histological analysis of the arterial stumps was performed. An ultrasound was performed 1 month postoperatively to check arterial patency. A clinical and functional evaluation was done at 1 month postoperative, then every 3 months. From 2018 to 2020, 46 patients were included with a maximum follow-up of 13 months. There were 35 cuts, 2 crush injuries, 8 amputation and 1 blast injury. Macroscopically, 37% of the margins were considered damaged. Histological analysis showed significant damage in 59% of the sections (27 out of 46 patients) with 50% for crush injury, 55% for cuts by mechanical tool, 62% for cuts by power tool, 62% for amputations and 100% for blasts. The failure rate was 9%: 2 replantations and 2 asymptomatic thromboses diagnosed by ultrasound. Postoperative pain on VAS was 1.75/10, range of motion was 87%, Quick DASH was 8%, SF36 PCS was 69% and SF36 MCS was 70%. Factors influencing the success or failure of anastomosis were the mechanism of injury (p = 0.02), associated nerve damage (p = 0.014) and length of proximal arterial cut (p = 0.046). Histological arterial lesions seem to correlate with the injury mechanism. Cuts caused by glass or crush injuries do not seem to require arterial resections of more than 2 mm. A continuation of the study with a larger number of subjects may generate statistically significant results.

Oral sedation in dentistry: evaluation of professional practice of oral hydroxyzine in the University Hospital of Rennes, France.

PURPOSE: Management of a child's anxiety early in their treatment is essential in dentistry. Sedative medications are used to overcome increased anxiety from previous appointments and to promote the cooperation of children during treatment. Hydroxyzine is currently prescribed to young patients as part of the first level of conscious sedation. The main objective was to evaluate the professional practice of oral hydroxyzine, when prescribed for children presenting anxiety during dental treatment procedure performed by students and senior practitioners. METHODS: A retrospective study of dental records and questionnaires was conducted at the Dental Care Centre of the University Hospital of Rennes, France. Parameters related to the prescription of hydroxyzine in children were evaluated as potential predictors of the dental session success, with adjustments on potential confounders. RESULTS: The therapeutic outcome was very encouraging with 78.3% of success during dental sessions under sedation with oral hydroxyzine. Anxiety levels before the dental procedure and the medication compliance of the child were the main predictors of success. On the other hand, lower age (< 6 years old) and longer treatments (such as pulpotomy) worsened the outcome. CONCLUSIONS: Careful analysis of the literature and results of this work showed the safety of hydroxyzine within the maximum dose authorized without adverse effects, compared to other molecules described and commonly used in dentistry. No adverse effects during dental procedure were noted. This allows for minimal sedation with efficiency for the great majority of pediatric treatment. This solution should be the first step in sedation to help practicing clinicians.

Traumatic pedestrian and bicyclist injuries associated with intoxication.

BACKGROUND: Drug and alcohol use are risk factors for trauma among operators of motor vehicles and contribute to trauma in pedestrians and bicyclists. We describe the prevalence of drug and alcohol use and clinical consequences in a cohort of pedestrians and bicyclists with trauma. METHODS: We analyzed a 25-month data set of 916 trauma team activations from January 2017-January 2019 at an urban, level I trauma center. Blood ethanol levels and urine toxicology screens were obtained in 94 pedestrian and bicyclist trauma activations. We compared pedestrians or bicyclists with a positive urine or blood screen (n = 69) to those with negative screens (n = 25). We conducted a retrospective chart review to determine mechanism of injury, injury pattern, and disposition from the emergency department (ED). RESULTS: Overall, 38 (55%) of injured patients with positive screen were pedestrians and 31 (45%) were bicyclists. Fentanyl was the most commonly detected drug (n = 38; 40%), followed by opiates (n = 27; 29%), and tetrahydrocannabiol (THC) (n = 23; 25%). Twenty-one patients were positive for ethanol. Pedestrians and bicyclists with positive toxicology screens were significantly more likely to sustain fractures (p < .01), require an operative procedure (p < .05), or intensive care unit admission (p < .05). CONCLUSION: Our study builds on previous literature which suggests that intoxicated bicyclists and pedestrians suffer frequent and more severe injury than their sober counterparts. Public health campaigns should educate bicyclists and pedestrians about the risks of cycling or walking in areas of road traffic while under the influence of alcohol or illicit drugs.

Intentional Hydroxychloroquine Overdose Treated with High-Dose Diazepam: an Increasing Concern in the COVID-19 Pandemic.

INTRODUCTION: Recent attention on the possible use of hydroxychloroquine and chloroquine to treat COVID-19 disease has potentially triggered a number of overdoses from hydroxychloroquine. Toxicity from hydroxychloroquine manifests with cardiac conduction abnormalities, seizure activity, and muscle weakness. Recognizing this toxidrome and unique management of this toxicity is important in the COVID-19 pandemic. CASE REPORT: A 27-year-old man with a history of rheumatoid arthritis presented to the emergency department 7 hours after an intentional overdose of hydroxychloroquine. Initial presentation demonstrated proximal muscle weakness. The patient was found to have a QRS complex of 134 ms and QTc of 710 ms. He was treated with early orotracheal intubation and intravenous diazepam boluses. Due to difficulties formulating continuous diazepam infusions, we opted to utilize an intermitted intravenous bolus strategy that achieved similar effects that a continuous infusion would. The patient recovered without residual side effects. DISCUSSION: Hydroxychloroquine toxicity is rare but projected to increase in frequency given its selection as a potential modality to treat COVID-19 disease. It is important for clinicians to recognize the unique effects of hydroxychloroquine poisoning and initiate appropriate emergency maneuvers to improve the outcomes in these patients.

Chloroquine, hydroxychloroquine and COVID-19.

The media have featured the antimalarials chloroquine (CQ) and hydroxychloroquine (HCQ) to treat coronavirus (COVID-19). Political leaders have touted their use and recommended availability to the public. These anti-inflammatory agents have substantial human toxicity with a narrow therapeutic window. CQ and HCQ poisoning cause myocardial depression and profound hypotension due to vasodilation. Bradycardia and ventricular escape rhythms arise from impaired myocardial automaticity and conductivity due to sodium and potassium channel blockade. With cardiotoxicity, ECGs may show widened QRS, atrioventricular heart block and QT interval prolongation. CQ may also cause seizures, often refractory to standard treatment. Of concern is pediatric poisoning, where 1-2 pills of CQ or HCQ can cause serious and potentially fatal toxicity in a toddler. The treatment of CQ/HCQ poisoning includes high-dose intravenous diazepam postulated to have positive ionotropic and antidysrhythmic properties that may antagonize the cardiotoxic effects of CQ. Infusions of epinephrine titrated to treat unstable hypotension, as well as potassium for severe hypokalemia may be required. Current scientific evidence does not support treatment or prophylactic use of these agents for COVID-19 disease. Regulatory and public health authorities recognize that CQ/HCQ may offer little clinical benefit and only add risk requiring further investigation before wider public distribution.

Surgical treatment of phlegmons of the digital flexor tendon sheaths at the early stage: Lavage by conventional open technique versus ultrasound-guided percutaneous technique.

The aim of this work was to analyze the results of a percutaneous drainage technique with 2 catheters during surgical treatment of phlegmons of the finger flexor tendon sheath. Our series included 32 patients with a phlegmon of flexor tendon sheaths, including 19 men and 13 women, mean age 43.4years. The first 16 patients (group I) were treated by a conventional open technique for the lavage and drainage of the affected tendon sheath. The last 16 (group II) were treated by an ultrasound-guided percutaneous lavage technique with 2 catheters: one proximal and one distal. In the case of impermeability of the digital canal, conversion by open technique was carried out. In group II, the ultrasound-guided percutaneous lavage was 5 times successful. Failure of the proximal catheter alone was noted once, whereas failure of the distal catheter alone was noted 7 times. The failure of both catheters was noted 3 times. At a mean follow-up of 19.7 days, mean handgrip strength was 56.5% compared to the contralateral side in group I and 82% in group II (P<0.05). However, there was no significant difference for pain, QuickDASH, total active mobility between group I and group II. Pain was at 1.4/10 for group I and 1.4/10 for group II. QuickDASH was measured at 27/100 for group I and 22.27/100 for group II. Total active mobility was 227° for group I and 243° for group II. In conclusion, surgical treatment of the phlegmons of the finger flexor tendon sheath with an ultrasound-guided percutaneous lavage technique gives significantly better short-term grip strength than the conventional open technique.

Designing a minimally-invasive, ultrasound-guided, percutaneous flexor tendon sheath lavage technique: a cadaver study.

The goal of this study was to develop a minimally-invasive, ultrasound-guided percutaneous flexor tendon sheath lavage technique on cadaver model. Two catheters were inserted using ultrasound guidance at the proximal and distal ends of the tendon sheath in 20 fingers from cadaveric forearms. Percutaneous injection of a saline solution colored with methylene blue resulted in anterograde lavage of the flexor tendon sheath. The technique was successful in 13 out of 20 cases. The proximal catheter was in the correct position in 17 cases and the distal catheter was correctly positioned in 15 cases. The flexor tendons were continuous in all cases and had puncture wounds in 9 cases. Based on our study, this minimally-invasive, ultrasound-guided percutaneous lavage of the flexor tendon sheath was effective in 65% of cases and safe in 100% of cases in the index, middle and ring fingers. If this percutaneous lavage fails, it is always possible to switch to a conventional open technique.

Two-team management of vascular injuries concomitant with osteo-articular injuries in 36 patients over six years.

BACKGROUND: Patients with both vascular and osteoarticular injuries require multidisciplinary management. Vascular injuries may be function- and/or life-threatening. The lower limbs are predominantly affected. Traffic, domestic, and work-related accidents contribute most of the cases. The primary objective of this study was to describe the management of patients with concomitant vascular and osteo-articular injuries, with special attention to the rates of amputation and fasciotomy. The secondary objective was to suggest a management sequence to optimise our surgical practice. HYPOTHESIS: The management sequence is a crucial consideration in patients with both vascular and osteo-articular injuries. MATERIAL AND METHODS: A 6-year, retrospective, observational study was conducted in patients with concomitant vascular and osteo-articular injuries. RESULTS: The study included 36 patients with a mean age of 40.6±22.1 years. The main sources of injury were traffic accidents (n=19, 52.8%), crush injury (n=8, 22.2%), and falls (n=5, 13.9%). A compound fracture was present in 20 (55.6%) patients. Evidence of ischaemia in 25 (69.4%) patients, and bleeding in 11 (30.6%) patients. Pre-operative imaging, by ultrasonography or computed tomography, was performed in 27 (75.0%) patients. The lower limb was involved in 30 (83.3%) patients, who had osteoarticular injuries to the femur and leg combined with injury to the popliteal artery. Fasciotomy was performed in 11 (30.6%) patients and secondary amputation in 7 (19.4%) patients. The limb salvage rate was 80.6%. Median patient survival was 9.3 [0-74.8] months. DISCUSSION: Coordinated work by two surgical teams is crucial to manage concomitant vascular and osteo-articular injuries. The management sequence must be defined clearly. Computed tomography angiography is the investigation of choice and should be performed at the slightest suspicion of vascular injury. LEVEL OF EVIDENCE: IV, retrospective observational study.

Radiation exposure and the orthopedic surgeon's hand: Measurement of the equivalent dose over 13 months.

Exposure to ionizing radiation in the operating room is governed by practical prevention and protection measures on the international, national and local levels. We evaluated the equivalent dose to the hand of an orthopedic surgeon over 13 months. An orthopedic surgeon wore a ring dosimeter on the ring finger of his right hand for all surgical procedures requiring intraoperative fluoroscopy between March 2014 and April 2015. Monthly doses were evaluated by the IRSN over the study period. The number and type of procedures were compiled as well as the type of fluoroscopy unit used. Four hundred procedures were performed during this period, including 182 with fluoroscopy. The equivalent cumulative dose at the hand was 4,75 mSv. No correlation was found with the type of procedure or type of fluoroscopy unit (conventional or mini C-arm). Equivalent doses were below the annual regulatory limit in France of 500 mSv. These results are consistent with those reported in the literature. However, recent studies have noted that both younger surgeons in training and more experienced surgeons must remember to use radiation protection measures.

Cementless and locked prosthesis for the treatment of 3-part and 4-part proximal humerus fractures: prospective clinical evaluation of hemi- and reverse arthroplasty.

INTRODUCTION: Cemented stem remains the gold standard for prosthesis in trauma. The purpose of this study was to evaluate the functional and radiological outcomes of a cementless, trauma-specific locked stem (hemi and reverse) for 3- and 4-part proximal humeral fractures. MATERIALS AND METHODS: One hundred and thirty-four 3- and 4-part fractures have been treated by locked stem, 69 with hemiarthroplasty [mean age 68 years (50-90)] and 65 with reversed [mean age 78 years (66-91)]. The length of the stem was 15 cm with a proximal coating of HA automatic locking system (two screws) and four different diameters. Preliminary cadaver study allowed us to validate the system (22 shoulders, no injuries of nerves, locking system efficient). RESULTS: In the group of hemi, Constant score with ponderation reached 72 (11-120) and QDash 31.2 (4.5-77.27) with a mean FU of 25 months (6-96). In the group of reversed, Constant score with ponderation reached 77.6 (28.8-119) and QDash 36.2 (2-84) with a mean FU of 15 months (6-41). Specific complications due to locking system reached 3% but without reoperation. Other complications were capsulitis and infection. DISCUSSION: In this population of elderly patient, new fall with periprosthetic fracture or infection led the surgeon to remove the stem. At shoulder level, the removal of a cemented stem remains a highly demanding procedure with sometimes bad functional results and elevated level of complications. This series is the first one of locked stem without significant complications. Locked stem remains a new but logical tool in trauma.

[Treatment of extra-articular distal radius fractures in active elderly patients]. / Traitement des fractures extra-articulaires de l'extrémité distale du radius du sujet âgé autonome.

Extra-articular distal radius fractures in active elderly patients are common and predominantly affect females. The high number of patients lost to follow-up compromises the evaluation of outcomes. Treatment aims to control the comminution and allow fast recovery of pre-injury activity levels. Fixation with volar locking plates is the gold standard. The role of bone substitutes in this type of injury is unclear.

Antibiotic-associated diarrhoea in emergency department observation unit patients.

Clostridium difficile diarrhoea is an urgent threat to patients, but little is known about the role of antibiotic administration that starts in emergency department observation units (EDOUs). We studied risk factors for antibiotic-associated diarrhoea (AAD) and C. difficile infection (CDI) in EDOU patients. This prospective cohort study enrolled adult patients discharged after EDOU antibiotic treatment between January 2013 and 2014. We obtained medical histories, EDOU treatment and occurrence of AAD and CDI over 28 days after discharge. We enrolled and followed 275 patients treated with antibiotics in the EDOU. We found that 52 (18·6%) developed AAD and four (1·5%) had CDI. Patients treated with vancomycin [relative risk (RR) 0·52, 95% confidence interval (CI) 0·3-0·9] were less likely to develop AAD. History of developing diarrhoea with antibiotics (RR 3·11, 95% CI 1·92-5·03) and currently failing antibiotics (RR 1·90, 95% CI 1·14-3·16) were also predictors of AAD. Patients with CDI were likely to be treated with clindamycin. In conclusion, AAD occurred in almost 20% of EDOU patients with risk factors including a previous history of diarrhoea with antibiotics and prior antibiotic therapy, while the risk of AAD was lower in patients receiving treatment regimens utilizing intravenous vancomycin.

The Relationship between Methamphetamine Use and Dental Caries and Missing Teeth.

PURPOSE: This study examined the relationship between methamphetamine use and oral health status. METHODS: Using a cross-sectional design, data were collected in 1998 from 174 newly admitted prisoners in Iowa. Oral examinations identified dental caries and missing teeth, and personal interviews identified methamphetamine use and covariates. Descriptive statistics were used to summarize the data, and bivariate and multivariate linear regression analyses, including testing for interaction effects, were used to examine the effects of methamphetamine use on oral health status. RESULTS: Multivariate regression analyses for carious teeth and surfaces showed significant interaction effects: methamphetamine*race/ethnicity (carious teeth: p=0.039; surfaces: p=0.023) and methamphetamine*tooth brushing when on drugs (carious teeth: p=0.044; surfaces: p=0.035). Methamphetamine use had a significant effect on dental caries among Non-Whites and among those who brushed their teeth less than once a day when on drugs. Soda consumption (carious teeth: p=0.026; surfaces: p=0.030) and reason for last dental visit (carious teeth: p=0.025; surfaces: p=0.011) were also associated with caries. For missing teeth there was a significant methamphetamine*race/ethnicity interaction (p=0.028) among Whites who used methamphetamine compared to Whites who did not use methamphetamine. Age (p=0.0001) and reason for last dental visit (p=0.0001) were also associated with missing teeth. CONCLUSION: The effect of methamphetamine use on missing teeth was moderated by race/ethnicity,; while its effect on dental caries was moderated by race/ethnicity and tooth brushing when on drugs.

The role of tonsillectomy in the initial diagnostic work-up of head and neck squamous cell carcinoma of unknown primary.

OBJECTIVE: The aim of the present study was to determine the value of tonsillectomy in the initial diagnostic work-up of head and neck squamous cell carcinoma of unknown primary (HNSCCUP). MATERIAL AND METHODS: A single-center retrospective study (1999­2012) included 45 patients. All cases underwent physical examination, panendoscopy and contrast-enhanced neck and chest CT scan; 27 (60%)also underwent 18-FDG PET scan. Imaging was systematically performed before panendoscopy. In 34 cases (75%), histologic tonsil samples ipsilateral to the HNSCCUP were collected (28 tonsillectomies and 6 biopsies) during panendoscopy. Categoric variables were compared on Chi-square test. RESULTS: Clinical examination and CT did not identify any primary tumor. In 13 cases (38%), invasive squamous cell carcinoma (SCC) was diagnosed on histological samples (12 tonsillectomies, 1 biopsy). For these 13 cases, lymph nodes were located in the upper or middle jugular group, and in 3 cases lymph nodes were cystic on CT scan. In 7 cases (26%), there was an abnormal tonsillar 18-FDG uptake ipsilateral to the cervical lymphadenopathy; tonsillectomy was performed, and SCC was found in 5 of these cases:i.e., 18-FDG PET showed sensitivity and specificity of respectively 55.5 and 88.8%. CONCLUSION: Tonsillectomy has a role in the initial diagnostic work-up of HNSCCUP. It is especially useful when lymph nodes are located in the upper and/or middle jugular group with a cystic aspect on CT.

Primary care physicians' decisions about discharging patients from their practices.

OBJECTIVE: There are few data available about factors which influence physicians' decisions to discharge patients from their practices. To study general internists' and family medicine physicians' attitudes and experiences in discharging patients from their practices. DESIGN: A cross-sectional mailed survey was used. PARTICIPANTS: One thousand general internists and family medicine physicians participated in this study. MEASUREMENTS AND MAIN RESULTS: We studied the likelihood physicians would discharge 12 hypothetical patients from their practices, and whether they had actually discharged such patients. The effect of demographic data on the number of scenarios in which patients were likely to be discharged, and the number of patients actually discharged were analyzed via ANOVA and multiple logistic regression analysis. Of 977 surveys received by subjects, 526 (54%) were completed and returned. A majority of respondents were willing to discharge patients in 5 of 12 hypothetical scenarios. Eighty-five percent had actually discharged at least one patient from their practices. Most respondents (71%) had discharged 10 or fewer patients, but 14% had discharged 11 to 200 patients. Respondents who were in private practice (p < 0.000001) were more likely to discharge both hypothetical and actual patients from their practices. Older physicians (> or =48 years old) were more likely to discharge actual patients from their practices (p = 0.005) as were physicians practicing in rural settings (p = 0.003). CONCLUSIONS: Most physicians in our sample were willing to discharge actual and hypothetical patients from their practices. This tendency may have significant implications for the initiation of pay-for-performance programs. Physicians should be educated about the importance of the patient-physician relationship and their fiduciary obligations to the patient.

Nitrogen isotopes as indicators of NO(x) source contributions to atmospheric nitrate deposition across the midwestern and northeastern United States.

Global inputs of NO(x) are dominated by fossil fuel combustion from both stationary and vehicular sources and far exceed natural NO(x) sources. However, elucidating NO(x) sources to any given location remains a difficult challenge, despite the need for this information to develop sound regulatory and mitigation strategies. We present results from a regional-scale study of nitrogen isotopes (delta15N) in wet nitrate deposition across 33 sites in the midwestern and northeastern U.S. We demonstrate that spatial variations in delta15N are strongly correlated with NO(x) emissions from surrounding stationary sources and additionally that delta15N is more strongly correlated with surrounding stationary source NO(x) emissions than pH, SO4(2-), or NO3- concentrations. Although emission inventories indicate that vehicle emissions are the dominant NO(x) source in the eastern U.S., our results suggest that wet NO3- deposition at sites in this study is strongly associated with NO(x) emissions from stationary sources. This suggests that large areas of the landscape potentially receive atmospheric NO(y) deposition inputs in excess of what one would infer from existing monitoring data alone. Moreover, we determined that spatial patterns in delta15N values are a robust indicator of stationary NO(x) contributions to wet NO3- deposition and hence a valuable complement to existing tools for assessing relationships between NO3- deposition, regional emission inventories, and for evaluating progress toward NO(x) reduction goals.

Lyme meningoradiculitis: prospective evaluation of biological diagnosis methods.

The symptoms of Lyme meningoradiculitis and the value of biological examinations in an endemic area were determined in a prospective study in which data were collected on all patients consecutively hospitalised for Lyme meningoradiculitis at our institution during an 18-month period. Specific antibody titres in the serum and cerebrospinal fluid (CSF) were determined by Vidas enzyme-linked-immunosorbent-assay (IgG + IgM), Dade-Behring enzyme immunoassay (EIA) (IgM; IgG) and Western blot analysis (IgG). We also searched for Borrelia burgdorferi in the CSF by PCR analysis and following culture on a specific medium. A control group was recruited, consisting of 16 consecutive patients who had been referred during the same period with suspected but not confirmed Lyme meningoradiculitis. Eleven patients were included. Borrelia EIA of the serum revealed that 40% of the patients had both elevated specific IgM titres and intrathecal synthesis of specific IgG; 40% of the patients was negative for IgM but had isolated intrathecal synthesis of IgG; 20% of the patients had elevated specific IgM titres without intrathecal synthesis of IgG. PCR analysis and the CSF culture were positive in one case only (B. garinii). The results of this study highlight the importance of systematic serological testing for B. burgdorferi in the CSF in the case of early neuroborreliosis suspicion, even in the absence of IgM serum antibodies, which was the case in 40% of the patients in the present study. Nevertheless, intrathecal anti-B. burgdorferi IgG synthesis, which remains the "gold standard" for the diagnosis of neuroborreliosis, was not detectable in 20% of the patients for whom diagnosis was subsequently confirmed by demonstration of specific serum IgM.