Cortical morphology predicts placebo response in multiple sclerosis

Despite significant insights into the neural mechanisms of acute placebo responses, less is known about longer-term placebo responses, such as those seen in clinical trials, or their interactions with brain disease. We examined brain correlates of placebo responses in a randomized trial of a then controversial and now disproved endovascular treatment for multiple sclerosis. Patients received either balloon or sham extracranial venoplasty and were followed for 48 weeks. Venoplasty had no therapeutic effect, but a subset of both venoplasty- and sham-treated patients reported a transient improvement in health-related quality of life, suggesting a placebo response. Placebo responders did not differ from non-responders in total MRI T2 lesion load, count or location, nor were there differences in normalized brain volume, regional grey or white matter volume or cortical thickness (CT). However, responders had higher lesion activity. Graph theoretical analysis of CT covariance showed that non-responders had a more small-world-like CT architecture. In non-responders, lesion load was inversely associated with CT in somatosensory, motor and association areas, precuneus, and insula, primarily in the right hemisphere. In responders, lesion load was unrelated to CT. The neuropathological process in MS may produce in some a cortical configuration less capable of generating sustained placebo responses.

A discrepant presentation of bacteremia in the emergency department linked to a Fusobacterium nucleatum infection: a case report

Background Fusobacterium nucleatum is an anaerobic bacterium mainly responsible for acute or chronic infection of the ear, nose, and throat, potentially bacteremic with a risk of extraoral metastatic infection. Bacteremia occurs mainly in the elderly or in immunodeficient individuals, with high mortality. F. nucleatum is not the first cause of tonsillar infection in emergency departments, which are more often the consequence of a viral or streptococcal infection, but it is a risk factor for severe bacterial infection, especially in a viral pandemic context. Case presentation A 25-year-old European woman with no history presented to the emergency department with fever (38.9 °C), pharyngeal symptoms, intermittent headaches, and alteration of general condition. On examination, she presented odynophagia associated with moderate tonsillar hypertrophy, her neck was painful but flexible. A rapid diagnostic test for beta-hemolytic group streptococcus was negative. First biological analyses revealed an inflammatory syndrome with C-reactive protein of 76 mg/L. Procalcitonin was measured secondarily, and was 2.16 µg/L. Faced with discordant clinical and biological findings, a lumbar puncture was performed, which came back negative. At hour eight, hypotension was observed but corrected after filling with physiological serum. The patient was hospitalized for monitoring, based on a hypothesis of severe viral presentation. At hour 24, pyrexia confirmed this hypothesis. A spontaneous but transient improvement and no new hemodynamic event led to early discharge. At day three, she was rehospitalized for increased and continuous headaches, without hemodynamic severity. A broad-spectrum probabilistic antibiotic therapy of ceftriaxone and metronidazole was started due to first blood cultures positive for anaerobic Gram-negative bacilli, while waiting for identification of the pathogen. Three days later, F. nucleatum was identified. According to the microbiological results, antibiotic therapy was adapted with amoxicillin and clavulanic acid, and no further complications were observed during clinical or complementary examinations. The final diagnosis was a F. nucleatum oropharyngeal infection complicated by bacteremia, without metastatic spread. Conclusion The etiologies of tonsillar infection are not limited to benign viruses or bacteria. These should not be overlooked in emergency medicine, especially when the clinical presentation is discrepant. A combination of early bacterial investigations as blood culture and close clinical monitoring is the only safe way to detect bacteremia, especially in immunocompetent patients.

573 Different renal function patterns in acute heart failure patients

Aims The role of worsening renal function during acute heart failure (AHF) hospitalization is still debated. Very few studies have extensively evaluated the renal function (RF) trend during hospitalization by repetitive measurements. The aim of this study is to investigate the prognostic relevance of different RF trajectories together with the congestion status in hospitalized patients. Methods and results This is a post hoc analysis of a multi-centres study including 467 patients admitted with AHF who were screened for the Diur-AHF Trial. We recognized five main RF trajectories based on serum creatinine and estimated glomerular filtration rate (eGFR) behaviour: according to the RF curve our sample was divided into 1-stable (S), 2-transient improvement (TI), 3-permanent improvement (PI), 4-transient worsening (TW), and 5-persistent worsening (PW). The primary outcome was the combined endpoint of 180 days including all causes of mortality and re-hospitalization. We recruited 467 subjects with a mean congestion score of 3.5 ± 1.08 and a median creatinine value of 1.28 (1.00–1.70) mg/dl, eGFR 50 (37–65) ml/min/m2, and NTpro BNP 7000 (4200–11 700) pg/ml. A univariate analysis of the RF pattern demonstrated that TI and PW patterns were significantly related to poor prognosis [HR: 2.71 (1.81–4.05); P < 0.001; HR: 1.68 (1.15–2.45); P = 0.007, respectively]. Conversely, the TW pattern showed a significantly protective effect on outcome [HR: 0.34 (0.19–0.60); P < 0.001]. Persistence of congestion and BNP reduction ≥ 30% were significantly related to clinical outcome at univariate analysis [HR: 2.41 (1.81–3.21); P < 0.001 and HR: 0.47 (0.35–0.67); P < 0.001]. A multivariable analysis confirmed the independently prognostic role of TI, PW patterns, persistence of congestion, and reduced BNP decrease at discharge. Conclusions Various RF patterns during AHF hospitalization are associated with different risk(s). PW and TI appear to be the two trajectories related to worse outcome. Current findings confirm the importance of RF evaluation during and after hospitalization.

572 Different renal function patterns in acute heart failure patients

Aims The role of worsening renal function during acute heart failure (AHF) hospitalization is still debated. Very few studies have extensively evaluated the renal function (RF) trend during hospitalization by repetitive measurements. The aim of this study is to investigate the prognostic relevance of different RF trajectories together with the congestion status in hospitalized patients. Methods and results This is a post hoc analysis of a multi-centres study including 467 patients admitted with AHF who were screened for the Diur-AHF Trial. We recognized five main RF trajectories based on serum creatinine and estimated glomerular filtration rate (eGFR) behaviour: according to the RF curve our sample was divided into 1-stable (S), 2-transient improvement (TI), 3-permanent improvement (PI), 4-transient worsening (TW), and 5-persistent worsening (PW). The primary outcome was the combined endpoint of 180 days including all causes of mortality and re-hospitalization. We recruited 467 subjects with a mean congestion score of 3.5 ± 1.08 and a median creatinine value of 1.28 (1.00–1.70) mg/dl, eGFR 50 (37–65) ml/min/m2, and NTpro BNP 7000 (4200–11 700) pg/ml. A univariate analysis of the RF pattern demonstrated that TI and PW patterns were significantly related to poor prognosis [HR: 2.71 (1.81–4.05); P < 0.001; HR: 1.68 (1.15–2.45); P = 0.007, respectively]. Conversely, the TW pattern showed a significantly protective effect on outcome [HR: 0.34 (0.19–0.60); P < 0.001]. Persistence of congestion and BNP reduction ≥ 30% were significantly related to clinical outcome at univariate analysis [HR: 2.41 (1.81–3.21); P < 0.001 and HR: 0.47 (0.35–0.67); P < 0.001]. A multivariable analysis confirmed the independently prognostic role of TI, PW patterns, persistence of congestion and reduced BNP decrease at discharge. Conclusions Various RF patterns during AHF hospitalization are associated with different risk(s). PW and TI appear to be the two trajectories related to worse outcome. Current findings confirm the importance of RF evaluation during and after hospitalization.

Observational case series: six neurosurgical patients with septic shock demonstrating clinical improvement after a combination of standard care and blood purification

Background For patients with primary brain injury, septic shock is especially dangerous due to the possibility of secondary cerebral damage. The key factor of sepsis-associated brain injury is inflammatory mediators, pathogen and damage-associated molecular patterns (PAMPs, DAMPs) release. Theoretically, blood purification may be beneficial for patients with primary brain injury due to its possibility for fast removal of inflammatory mediators. Case presentation We report on six post-neurosurgery septic shock patients treated with combined blood purification (CBP), which included CRRT with high adsorption capacity membrane in combination with CytoSorb adsorber. Clinical improvement in the course of CBP was registered in all patients. Three patients had a stable clinical improvement; the other three patients had only a transient improvement due to underlying neurological and cardiac deficits aggravation. We observed septic shock reversal in four patients. The key observations of the case series are a significant decrease in MOF severity (measured by SOFA score) and in catecholamine need (not statistically significant). By the end of CBP we observed a significant decrease in blood lactate, PCT and IL-6 levels. Two patients demonstrated level of consciousness increase in the setting of CBP therapy measured by GCS and FOUR score. Conclusion This case series demonstrates that CBP therapy may have a role for septic shock patients with primary brain injury.

Performance of brazilian university handball players in the vertical jump after maximum strength training

This study aimed to analyze the performance of the vertical jump with counter movement (CMJ), in university handball athletes, immediately after the maximum strength training in multiple series and after 10 and 15min of rest. Twelve male athletes participated, age 20.9±2.4 years old, height 1.78±0.05m and Body Mass Index (BMI) 28.74±8.1kg/m2. After the tests and retests of 1 repetition maximum (1RM) for the dominant and non-dominant sides, in the leg extension, the volunteers performed crossover after 48 hours of the training sessions. CMJ measurements were collected before and immediately after each training protocol and after 10 and 15min of rest. Passive recovery between sets was three minutes. The intervals between training protocols were at least 45min. There were no statistical differences for the CMJ between the moments pre-, post-training session, 10 and 15min of rest in the different protocols, but progressive increases in the CMJ variables were observed, extending up to the 15th minute of rest, in all training protocols when comparing the results of the means of the CMJ variables of the moments post-training session, 10 and 15min of rest with the averages of the variables from the pre-training session, being more evident in the alternate unilateral protocol, which, unlike the other protocols of the study, performed series with the two lower limbs. It was evidenced that the training protocols of short duration and with high dynamic efforts, previously performed, influenced the performance of the CMJ, favoring for the transient improvement of the explosive muscular strength of the athletes.

Congenitally corrected transposition of the great arteries (CCTGA)

A 33-year-old man presented with a 3-week history of breathlessness and cough. He disclosed that he was informed regarding a heart defect as a child in his home country but was unaware of its nature and was never followed up. Examination revealed a pansystolic murmur (loudest at the apex), a hyperdynamic, displaced apex, and pulmonary oedema. An ECG showed atrial fibrillation with a regular broad-complex ventricular rhythm. Following electrical cardioversion, the ECG revealed complete heart block, therefore explaining the regular atrial fibrillation. An urgent transthoracic echocardiography (TTE) confirmed the anatomy of congenitally corrected transposition of the great arteries (CCTGA) with torrential tricuspid regurgitation and impaired systemic right ventricle. Cardiac MRI identified a ventricular septal defect which was not visible on TTE. The patient showed a transient improvement following fluid offloading and ACE inhibition, with a more definitive improvement after cardiac resynchronisation therapy (CRT).