[Social or judicial alert in child abuse: Announcement guidelines and simulation in child welfare training with standardized patients]. / Information préoccupante ou signalement dans les violences intrafamiliales : construction, validation et mise en application d'une grille d'annonce par technique de simulation en santé avec patients standardisés.

Child abuse is a major health problem that can lead to physical and psychological issues. Its diagnosis can be difficult and sensitive. Physicians are submitted by law to inform the parents when they report to child welfare services or judicial authorities, unless otherwise in the minor's interest. This exercise is destabilizing for both patients and physicians. The physician must be trained to detect and announce a possible diagnosis of child abuse. To facilitate and increase those reports, we have developed guidelines for the physicians to help the exercise of announcement. These guidelines were based on pre-existing recommendations about how to announce bad news. We have also planned to put into practice these guidelines with a communication skills training program based on standardized patients. We propose the acronym PROTECT; P for plural: never stay alone in such situations, R for remaining a caregiver and not becoming an investigator or judge, O for obligation to protect minors, T for time, to take enough time to inform the parents and the child but in a limited time frame, E for explaining to the parents what preoccupy the professionals; C for centring ourselves on the child, his or her symptoms, needs and pain; T for total care of the child that should integrate physical, psychological, and social child health, through a global and interdisciplinary approach in collaboration with child welfare services, and should involve also the child in the process. This tool will be applied by simulation in child welfare training with standardized patients. The evaluation of this tool and its application would need further study.

[Minors in a French custody center: Sociodemographic characteristics, global health and vulnerability factors]. / Mineurs en garde à vue: caractéristiques sociodémographiques, auto-évaluation de la santé et identification de facteurs de vulnérabilité.

Minor offenders are at risk for medico-psycho-social vulnerability, that impacts global health, schooling, professional future, and socio-familial environment; moreover, minors who are victims of violence and neglect are at greater risk of becoming offenders and minor offenders are at greater risk of suffering violence. Few data are currently available regarding global health and vulnerability factors for minors (i.e. those aged under 18) who have been placed in police custody. This study aimed to describe the judicial and social characteristics of these minors, their medical and psychological health status, with the hypothesis that most minors placed in police custody can be considered as abused or neglected, by presenting factors of vulnerability. We carried out a prospective study, including consecutive minors aged of 13 to 18 years old, who had been detained in custody at the Central Police Station of Nantes (France), from October 2012 to May 2013. The sociodemographic characteristics, scores for global health and the data collected from the welfare and judiciary services were analyzed, to identify abused or neglected minors. Ninety-nine teenagers were included: 78 males and 11 females (mean age±standard deviation: 16.5 years±1.01), who had been placed in custody for robbery, with a remarkable proportion of recidivist minors. Our study has highlighted several worrying characteristics of minors in police custody reflecting their vulnerability, as living conditions (no schooling, no fixed address) and irregular or absent medical follow-up; however their scores for global health were not different from the general population. While 49 minors (49.5 %) had already been identified by the welfare services, our study find that 35 added minors of this population should nonetheless be considered as being abused and/or neglected, based on a very high rate of minors already followed by child protection services and/or already penalized. Systematic health screening in custody could help to detect abused and/or neglected minors, in order to provide them access to appropriate medical and social cares. They could be referring to psychiatric or rehabilitation cares, and to the relevant welfare and judiciary services in order to assess if a specific protection measure is needed.

Impact of COVID-19 pandemic on child abuse and neglect: A cross-sectional study in a French Child Advocacy Center.

OBJECTIVE: This study aimed to describe the impact of the first COVID-19 lockdown in France on the activity of a Child Advocacy Center. METHODS: This cross-sectional, observational study included all children involved in the activity of the CAC during the first lockdown, from March 16 to May 10, 2020 and the next 3 months and the corresponding periods in 2018 and 2019. Cases were considered severe when a hospitalization, social alert and/or judicial report to the prosecutor was decided. RESULTS: Data for 1583 children were analyzed. During the lockdown, the global center activity decreased with 26.4 consultations per 100.000 children in 2018, 46 in 2019 and 20.7 in 2020 (p < 0.001). Judicial activity decreased (forensic examinations and child forensic interview recordings), whereas assessment consultations increased. Cases were more severe during the lockdown than in 2019 and 2018 (12.3, 9.4 and 6.04/100.000 children, respectively, p < 0.0001). The global activity of the center increased in the 3 months after the lockdown as compared with during the lockdown (38.2/100.000 versus 20.7/100.000, respectively, p < 0.001) but did not differ from activity in 2018 and 2019. Severe cases were more frequent in the 3 months after the lockdown than the previous years (13.7/100.000 in 2020, 9.62 in 2019 and 8.17 in 2018, p = 0.0002). CONCLUSION: The CAC activity decreased during the lockdown in France but the increase in incidence of severe abuse cases during the lockdown and the next 3 months confirm the need for optimal screening, care and support of child abuse and neglect victims even in the context of health crisis.

[Burns by immersion in children and abuse]. / Brûlures par immersion chez l'enfant et maltraitance.

AIM OF THE STUDY: Ten percent of childhood burns could arise from maltreatment. While describing 6 severe cases of inflicted scalds by immersion in children, we expose our systematic diagnostic approach of abuse and confirm the serious nature of burn when they are inflicted. PATIENTS AND METHOD: The retrospective study concerned children hospitalized for scalds by immersion between 2013 and 2016 and for whom child abuse has been confirmed. Sex, age, burns description, needs of surgery, length of stay at hospital and protection plan set up were collected. RESULTS: Six cases of burns by immersion due to maltreatment were identified (5 boys, 1 girl) with a median age of 12 months. The average total burn surface area was 19%. Burns were of deep second and third degree and always symmetric. Every child underwent surgery at least once. Concern information was transferred for all of them. CONCLUSION: Teams taking care of children with burns must be trained to the difficult diagnostic of abuse or neglect so that early social interventions can be set up in case of maltreatment.

Long-term EEG in adults: sleep-deprived EEG (SDE), ambulatory EEG (Amb-EEG) and long-term video-EEG recording (LTVER).

Long-term EEG in adults includes three modalities: sleep deprived-EEG lasting 1 to 3 hours, 24 hours ambulatory-EEG and continuous prolonged video-EEG lasting from several hours to several days. The main indications of long-term EEG are: syndromic classification of epilepsy; search for interictal discharges when epilepsy is suspected or for the purpose of therapeutic evaluation; positive diagnosis of paroxysmal clinical events; and pre-surgical evaluation of drug-resistant epilepsy. Sleep deprived-EEG and ambulatory-EEG are indicated to detect interictal discharges in order to validate a syndromic classification of epilepsy when standard EEG is negative. These exams can help in evaluating treatment efficacy, especially when clinical evaluation is difficult. Long-term video EEG is indicated for drug-resistant epilepsy, to analyze electro-clinical correlations in a pre-surgical evaluation context, and to refine a positive diagnosis when paroxysmal clinical events are frequent.

Tele-transmission of EEG recordings.

EEG recordings can be sent for remote interpretation. This article aims to define the tele-EEG procedures and technical guidelines. Tele-EEG is a complete medical act that needs to be carried out with the same quality requirements as a local one in terms of indications, formulation of the medical request and medical interpretation. It adheres to the same quality requirements for its human resources and materials. It must be part of a medical organization (technical and medical network) and follow all rules and guidelines of good medical practices. The financial model of this organization must include costs related to performing the EEG recording, operating and maintenance of the tele-EEG network and medical fees of the physician interpreting the EEG recording. Implementing this organization must be detailed in a convention between all parties involved: physicians, management of the healthcare structure, and the company providing the tele-EEG service. This convention will set rules for network operation and finance, and also the continuous training of all staff members. The tele-EEG system must respect all rules for safety and confidentiality, and ensure the traceability and storing of all requests and reports. Under these conditions, tele-EEG can optimize the use of human resources and competencies in its zone of utilization and enhance the organization of care management.

[French guidelines on electroencephalogram]. / Recommandations françaises sur l'électroencéphalogramme.

Electroencephalography allows the functional analysis of electrical brain cortical activity and is the gold standard for analyzing electrophysiological processes involved in epilepsy but also in several other dysfunctions of the central nervous system. Morphological imaging yields complementary data, yet it cannot replace the essential functional analysis tool that is EEG. Furthermore, EEG has the great advantage of being non-invasive, easy to perform and allows control tests when follow-up is necessary, even at the patient's bedside. Faced with the advances in knowledge, techniques and indications, the Société de Neurophysiologie Clinique de Langue Française (SNCLF) and the Ligue Française Contre l'Épilepsie (LFCE) found it necessary to provide an update on EEG recommendations. This article will review the methodology applied to this work, refine the various topics detailed in the following chapters. It will go over the summary of recommendations for each of these chapters and underline proposals for writing an EEG report. Some questions could not be answered by the review of the literature; in those cases, an expert advice was given by the working and reading groups in addition to the guidelines.

[Contribution of the Dijon Stroke Registry after 20 years of data collection]. / Les apports du registre dijonnais des accidents vasculaires cérébraux en 20 ans d'activité

INTRODUCTION: The Dijon Stroke Registry is the only population-based registry in France which has collected neurological data without interruption for more than 20 years. This registry has produced reliable epidemiological data from a large non-selected population. PATIENTS AND METHODS: During the 20-year study period, 3142 ischemic strokes, 341 primary cerebral hemorrhages and 74 subarachnoid hemorrhages were recorded. Age at first stroke rose by five years in men and eight years in women. RESULTS: Comparing the descriptive epidemiology data between 1985 to 1989 and the 2000-2004 periods, the following results were noted: age- and sex-standardized incidences of first-ever stroke were stable except for lacunar stroke where the incidence increased significantly (p=0.05), and for cardioembolic stroke where incidence decreased significantly (p=0.01); 28-day case-fatality rates decreased significantly mainly for lacunar stroke (p=0.05) and for primary cerebral hemorrhage (p=0.03). The proportion of subjects with hypercholesterolemia and diabetes increased significantly (p<0.01). Analysis of cohort data issuing from the registry yielded the following findings: hyperglycemia during the acute stage of cerebral infarct was linked with poor prognosis; lower levels of E. apolipoprotein linked to HDL-cholesterol were associated with atherothrombotic infarcts; activation of coagulation factors was linked with atherothrombotic infarct; decreased N-acetyl-aspartate, a marker of the number of neurons, and increased serum lactate, a marker of anaerobic metabolism measured by proton magnetic resonance spectroscopy were noted in the cohort of cerebral infarct victims; release of platelet V-glycoprotein was noted in cerebral infarct; the incidence of cerebral infarct rose during autumn and during periods with high levels of atmospheric ozone and was higher in male smokers aged more than 40 years with hypertension. The population-based registry contributed to the assessment of medicoeconomic expenditures and professional practices. CONCLUSION: In Dijon, age- and sex-standardized stroke incidence has remained stable over the past 20 years. Increasing age at first-ever stroke, decreasing case-fatality rate, increasing use of antiplatelet treatments and a reduction in certain prestroke risk factors were noted.

Morphogenesis of a highly replicative EGFPVP22 recombinant Marek's disease virus in cell culture.

Marek's disease virus (MDV) is an alphaherpesvirus for which infection is strictly cell associated in permissive cell culture systems. In contrast to most other alphaherpesviruses, no comprehensive ultrastructural study has been published to date describing the different stages of MDV morphogenesis. To circumvent problems linked to nonsynchronized infection and low infectivity titers, we generated a recombinant MDV expressing an enhanced green fluorescent protein fused to VP22, a major tegument protein that is not implicated in virion morphogenesis. Growth of this recombinant virus in cell culture was decreased threefold compared to that of the parental Bac20 virus, but this mutant was still highly replicative. The recombinant virus allowed us to select infected cells by cell-sorting cytometry at late stages of infection for subsequent transmission electron microscopy analysis. Under these conditions, all of the stages of assembly and virion morphogenesis could be observed except extracellular enveloped virions, even at the cell surface. We observed 10-fold fewer naked cytoplasmic capsids than nuclear capsids, and intracellular enveloped virions were very rare. The partial envelopment of capsids in the cytoplasm supports the hypothesis of the acquisition of the final envelope in this cellular compartment. We demonstrate for the first time that, compared to other alphaherpesviruses, MDV seems deficient in three crucial steps of viral morphogenesis, i.e., release from the nucleus, secondary envelopment, and the exocytosis process. The discrepancy between the efficiency with which this MDV mutant spreads in cell culture and the relatively inefficient process of its envelopment and virion release raises the question of the MDV cell-to-cell spreading mechanism.

Stroke patterns in cardio-embolic infarction in a population-based study.

The study demonstrates that clinical-radiological causes and outcome of cardio-embolic infarcts in a population-based study correspond to a well-identified stroke pattern. Cardio-embolic infarcts was diagnosed in 882 cases (37.9%) of 2,330 consecutive first-ever stroke patients included in a prospective population-based stroke registry over a 14-year period (1985-1997). Thirty-three criteria out of 98 were introduced into a monovariate analysis and the significant variable were introduced into a multivariate analysis to identify significant criteria to define stroke patterns in cardio-embolic infarction. Cardiac sources of embolus included atrial arrhythmia, valvular heart disease (19%), and cardiac failure (18%). Patients with cardio-embolic infarction showed a significantly higher rate of female predominance (p < 0.001), history of ischemic heart disease (p < 0.001), acute stroke onset (p < 0.05), headache (p < 0.05), previous treatment by anti-platelets and anti-K-vitamin (p < 0.001), Wernicke aphasia (p < 0.001), severe deficit (p < 0.001) and death (p < 0.001). After a logistic procedure, female gender and ischemic heart disease were the two independent risk factors associated with cardio-embolic stroke. Cardio-embolic stroke is a specific subtype of stroke with its own clinical, radiological, etiological and prognostic characteristics. In the acute stage, it is necessary to identify quickly this type of stroke because of severe prognosis and appropriate treatment.

MMP-2 colocalizes with caveolae on the surface of endothelial cells.

We examined the spatial distribution of MMP-2 on the surface of human endothelial cells using immunofluorescence and confocal microscopy. Staining endothelial cells with MMP-2-specific antibodies revealed a punctate labeling at the basolateral side of the cell periphery, which colocalized with patches of caveolin-1, a major constituent of the caveolae. This colocalization was confirmed by immunogold electron microscopy. MT1-MMP, TIMP-2, and the alphavbeta3 integrin exhibited a similar pattern of staining, with pericellular patches that colocalized with either MMP-2 or caveolin-1. The presence of MT1-MMP and TIMP-2 in caveolae patches could be seen only after treatment with concanavalin A, which induced MMP-2 activation but had no noticeable effect on the pattern or intensity of MMP-2 immunostaining. In contrast, MMP-9 and TIMP-1 staining showed a pattern completely different from that of MMP-2 and TIMP-2, with positive spots uniformly distributed throughout the cell body. Our data show that MMP-2, its activator the MT1-MMP, and its proposed receptor, the alphavbeta3 integrin, are all targeted to the same membrane microdomains on the endothelial cell, thereby restricting matrix proteolysis to a limited microenvironment at the cell surface.

[Ischemic cerebrovascular stroke of arterial origin in the child]. / Les accidents vasculaires cérébraux ischémiques d'origine artérielle chez l'enfant.

Comparing stroke in children with stroke in adults can provide interesting information because age and cerebral plasticity induce specific clinical features and outcome. Arterial ischemic strokes are the most frequent in childhood although the problem is not one of arteriosclerosis. Arterial dissection, Moya-Moya syndrome, and cardioembolic and thrombogenic events induced by hemoglobin diseases and hyperhomocyteinemia must be detected at the first event. In some cases, onset is marked by head trauma or an infectious syndrome. The important feature is that outcome is better than in adults and is marked by onset of hemidystonia, partial epilepsy. Aphasia is benign if stroke arises before the child has learned to write.

[Contribution of magnetic resonance imaging in sclerotic combined degeneration of the spinal cord due to vitamin B12 deficiency]. / Intérêt de l'imagerie par résonance magnétique dans la sclérose combinée de la moelle par carence en vitamine B12.

Subacute combined degeneration (SCD) of the spinal cord is known to present histopathologically degenerative lesions in the spinal cord, but few studies on the neuroradiological findings have so far been reported. We present the interest of initial and follow-up MR findings in three cases of SCD. In the three cases, a causal event precipitated the onset of neurological symptoms: general anesthesia for the first and the third one and folic acid treatment for the second one. Clinical evolution was favorable after specific treatment with nearly total recovery. The initial MR study disclosed lesions predominantly involving the posterior columns of the spinal cord: high intensity on T2 weighted image was seen in the initial MR study and disappeared three months after treatment in correlation with good recovery, but with a delay. The recognition of this MR pattern suggests that MRI may be used in conjunction with clinical assessment to confirm the diagnosis and to monitor the efficacity of treatment in SCD.

Correlation between inter-ictal regional cerebral blood flow and sphenoidal electrodes--recorded inter-ictal spikes in mesial temporal lobe epilepsy.

The objective of this study was to assess the reliability of the diagnosis of mesial temporal lobe epilepsy using EEG and sphenoidal electrodes. Inter-ictal 99 m Tc-HMPAO SPECT scans were registered in 21 patients with confirmed mesial temporal lobe epilepsy identified by scalp EEG and sphenoidal electrodes. Visual and quantitative SPECT analysis was performed blind to EEG data. An asymmetry index (AI) was measured from the ratio of two symmetrical regions of interest. A temporal lobe hypoperfusion was defined as an uptake reduced by 5% with respect to the contralateral region. Inter-ictal SPECT abnormalities were observed in 12 out of 21 patients (57%) from both visual and quantitative analysis (focal hypoperfusion in 11 cases, focal hyperperfusion in one case). In seven patients (33%) both visual and quantitative scintigraphy were normal. Abnormal AI was found in 11/15 patients with a high frequency of seizures and in 1/6 patients with a low frequency of seizures. The major data is that the probability to have an abnormal SPECT is statistically correlated to the frequency of the epileptic fits. The couple EEG recordings with sphenoidal electrodes and SPECT is sensitive and reliable in the diagnosis of mesial temporal lobe epilepsy.

Variations in stroke incidence and survival in 3 areas of Europe. European Registries of Stroke (EROS) Collaboration.

BACKGROUND AND PURPOSE: Comparison of incidence and case-fatality rates for stroke in different countries may increase our understanding of the etiology of the disease, its natural history, and management. Within the context of an aging population and the trend for governments to set targets to reduce stroke risk and death from stroke, prospective comparison of such data across countries may identify what drives the variation in risk and outcome. METHODS: Population-based stroke registers, using multiple sources of notification, ascertained cases of first in a lifetime stroke between 1995 and 1997 for all age groups. The study populations were in Erlangen, Germany; Dijon, France; and London, UK. Crude incidence rates were age-standardized to the European population for comparative purposes. Case-fatality rates up to 1 year after the stroke were obtained, and logistic regression adjusting for age group, sex, and pathological subtype of stroke was used to compare survival in the 3 communities. RESULTS: A total of 2074 strokes were registered over the 3 years. The age-standardized rate to the European population was 100.4 (95% CI 91.7 to 109.1) per 100 000 in Dijon, 123.9 (95% CI 115.6 to 132.2) in London, and 136.4 (95% CI 124.9 to 147.9) in Erlangen. Both crude and adjusted rates were lowest in Dijon, France. The incidence rate ratio, with Dijon as the baseline comparison (1), was 1.21 (95% CI 1.09 to 1.34) in London and 1.37 (95% CI 1.22 to 1.54) in Erlangen (P:<0.0001). There were significant differences in the proportion of the subtypes of stroke between populations, with London having lower rates of cerebral infarction and higher rates of subarachnoid hemorrhage and unclassified stroke (P:<0.001). Case-fatality rates varied significantly between centers at 1 year, after adjustment for age, sex, and subtype of stroke (35% overall, 34% Erlangen, 41% London, and 27% Dijon; P:<0.001). CONCLUSIONS: The impact of stroke is considerable, and the risk of stroke varies significantly between populations in Europe as does the risk of death. The striking differences in survival require clarification but lend weight to the evidence that stroke management may differ between northern and central Europe and influence outcome.

Multi-variate analysis predicts clinical outcome 30 days after middle cerebral artery infarction.

BACKGROUND AND PURPOSE: To evaluate the functional prognostic value of proton magnetic resonance spectroscopy performed within the 5 days of an infarction of the middle cerebral artery territory, compared with previously demonstrated prognostic factors. METHODS: Proton magnetic resonance spectroscopy was performed on 77 consecutive non-comatosed patients during the acute stage of middle cerebral artery infarction. The functional status was determined for each patient via the Orgogozo score. Proton magnetic resonance spectroscopic data were acquired in the infarction and in contra-lateral normal tissue and the results were expressed as metabolite ratios. Correlations were evaluated between the Orgogozo score at day 1 and day 30, the age, the sex, the volume of the infarction, and the metabolic ratios. RESULTS: In a monovariate analysis, the decrease of the NAA/choline ratio was correlated with a low Orgogozo score at days 1 and 30 (P<0.05) and with a large infarction (P<0.05). A stepwise analysis showed a significant relationship between the Orgogozo score at day 30 and the Orgogozo score at day 1, the sex, the volume of infarction, and the NAA/Cho ratio within the infarction. CONCLUSIONS: Our work demonstrates that a good clinical outcome at day 30 depends on a good initial clinical score at day 1, a small volume of infarction, a small decrease of NAA/Cho, and being of the female gender.

Incidence of multiple sclerosis in Dijon, France: a population-based ascertainment.

Incidence of multiple sclerosis (MS) was prospectively determined within the population of the city of Dijon (94,000 inhabitants under 60 years old) at 47 degrees northern latitude, in Burgundy, France. All the incident cases were diagnosed according to the criteria of Poser, associated to the study of cerebrospinal fluid, evoked potentials and cerebral magnetic resonance imaging. Diagnosis was assessed in all the cases by a neurologist working either in the University Hospital (four neurologists) or in private offices (seven neurologists). The ascertainment was performed on a full 5-year period, from 1993 to 1997. Twenty-one cases were diagnosed in the population of 94,000 inhabitants, with an incidence of 6.1/100,000/year in women, 3.3/100,000/year in men and 4.3/100,000/year in both sexes. The sex-ratio female/male was 2.5. Our data are similar to those of the literature, in particular in countries around the Burgundy area. Our data allow evaluation of the burden of MS in our area and allow evaluation of the changes of incidence in the future.

Cerebral metabolism after transient ischemic attack. A 1H MR spectroscopy study.

Metabolic changes induced by cerebral infarction or by stenosis and occlusion of the internal carotid artery have been previously described in 1H Magnetic Resonance Spectroscopy (1H MRS). These changes are essentially characterized by decreased N-acetyl-aspartate (NAA) and increased lactate concentration. Little is known about the metabolic changes observed in the three days following a transient ischemic attack (TIA), in the absence of stenosis or occlusion of the internal carotid artery, and without visible infarction on Magnetic Resonance Imaging (MRI). We studied five patients with a TIA lasting between 30 min and 3 h, affecting the sensory and motor functions of the brachio-facial territory with or without aphasia. A Computerized Tomography Scan (CT-scan), an electro-encephalogram, cervical Doppler ultrasound and MRI with proton magnetic resonance spectroscopy were performed on the affected cerebral area and on the normal contralateral homologous cerebral area within three days of the onset of TIA. None of the five patients had stenosis or occlusion of the internal carotid artery on Doppler ultrasound, or cerebral infarction on MRI. From 1H MRS ratio measurements, we did not observe any significant changes in the NAA/Creatine ratio. However, a rise in Lactate/Creatine ratio was observed in the symptomatic non-infarcted area compared with the normal cerebral tissue. During the first three days following a transient ischemic attack, there is an increase in lactate production. This change may reflect transient local hypoperfusion which could be long enough to stimulate lactate production, but short enough not to induce infarction. This region could be at risk from infarction in the long term.