On the scene: American University of Beirut Medical Center, Beirut, Lebanon

American University of Beirut Medical Center is the first Magnet hospital in the Middle East. In this article, authors reflect back on the journey to excellence, specifically in establishing shared governance in a challenging cultural and organizational milieu. Perspectives from nurses at different levels are included to highlight their experiences throughout the journey. Evolution of the organization's shared governance model is described and initiatives of the councils are illustrated.     

Progression of striatal and extrastriatal degeneration in multiple system atrophy: A longitudinal diffusion‐weighted MR study

Diffusion‐weighted imaging has been largely used to detect and quantify early degenerative changes in patients with multiple system atrophy, but progression of neurodegeneration has been poorly investigated. We performed a serial diffusion‐weighted imaging study in a population of multiple system atrophy patients and analyzed the evolution of diffusion properties in striatal and extrastriatal brain regions. Diffusion‐weighted imaging was obtained in 11 multiple system atrophy patients at baseline and after a follow‐up of 11.7 ± 1.2 months, and Trace (D) changes in different brain regions were correlated with disease duration and severity. A significant increase in Trace (D) was observed at follow‐up in the putamen (P < .001), pons (P = .003), cerebellar white matter (P = .03), thalamus (P = .013), and frontal white matter (P = .021). Both Unified Multiple System Atrophy Rating Scale Part II and Unified Parkinson's Disease Rating Scale Part III scores significantly increased at follow‐up (P = .003), but percent changes of Unified Parkinson's Disease Rating Scale Part III and Unified Multiple System Atrophy Rating Scale Part II did not correlate with percent changes of Trace (D) values in any brain region. This longitudinal study provides new insights into the progression of neurodegeneration in different brain regions in multiple system atrophy. Our results confirm that abnormal diffusivity in the putamen is sensitive to change over time in multiple system atrophy patients and show for the first time a progression of Trace (D) alterations in specific extrastriatal regions. Diffusivity changes in these regions may be useful for monitoring disease progression even after a short follow‐up period. © 2011 Movement Disorder Society     

Comorbid major depression in obsessive-compulsive disorder patients

Although major depressive disorder (MDD) has been consistently considered the most frequent complication of obsessive-compulsive disorder (OCD), little is known about the clinical characteristics of patients with both disorders. This study assessed 815 Brazilian OCD patients using a comprehensive psychiatric evaluation. Clinical and demographic variables, including OCD symptom dimensions, were compared among OCD patients with and without MDD. Our findings showed that prevalence rates of current MDD (32%) and lifetime MDD (67.5%) were similar for both sexes in this study. In addition, patients with comorbid MDD had higher severity scores of OCD symptoms. There was no preferential association of MDD with any particular OCD symptom dimension. This study supports the notion that depressed OCD patients present more severe general psychopathology.     

The “eye of the tiger” sign in pure akinesia with gait freezing

The “eye of the tiger” is a neuroradiologic sign due to iron deposition in the globus pallidus: it appears as diffuse low signal intensity with a central area of high signal intensity confined to the globus pallidus. The “eye of the tiger” sign has been associated with neurodegeneration with brain iron accumulation type 1 (NBIA1), a condition caused by mutations in the gene encoding pantothenate kinase 2 (PANK2). However, the specificity of this neuroradiologic sign has been already challenged and it has been described in other neurodegenerative diseases. Here, we report the first case of a patient suffering from pure akinesia with gait freezing with the “eye of the tiger” sign in T2-weighted MRI sequences. All clinical, laboratory and radiologic data excluded other diagnosis and genetic testing excluded PANK2 mutations suggesting that the “eye of the tiger” is not specific for NBIA1 and may also occur in other movement disorders.     

A bronchoalveolar lavage-driven antimicrobial treatment improves survival in hematologic malignancy patients with detected lung infiltrates: A prospective multicenter study of the SEIFEM group

Bronchoalveolar lavage (BAL) is recommended for diagnosing lung infiltrates (LI) in patients with hematologic malignancy (HM). Prospective data on the impact of BAL on survival are still lacking. We conducted a prospective observational study on patients who performed BAL for LI among 3055 HM patients hospitalized from January to September 2018. The BAL was performed in 145 out of 434 patients who developed LI, at a median time of four days from LI detection. The median age was 60 (1-83). Most patients had an acute myeloid leukemia/myelodisplastic syndrome (81), followed by lymphoma (41), acute lymphoblastic leukemia (27), and other types of HM (36). A putative causal agent was detected in 111 cases (76%), and in 89 cases (61%) the BAL results provided guidance to antimicrobial treatment. We observed a significantly improved outcome of LI at day +30 in patients who could receive a BAL-driven antimicrobial treatment (improvement/resolution rate: 71% vs 55%; P = .04). Moreover, we observed a significantly improved outcome in 120-day overall survival (120d-OS) (78% vs 59%; P = .009) and 120-day attributable mortality (120d-AM) (11% vs 30%; P = 0.003) for patients who could receive a BAL-driven treatment. The multivariate analysis showed that BAL-driven antimicrobial treatment was significantly associated with better 120d-OS and lower 120d-AM. We did not observe any severe adverse events. In conclusion BAL allows detection of a putative agent of LI in about 75% of cases, it is feasible and well tolerated in most cases, demonstrating that a BAL-driven antimicrobial treatment allows improvement of clinical outcome and survival.     

Pattern ERG and RNFL thickness in hypertensive eyes with normal blue-yellow visual field

Purpose

To evaluate the transient pattern electroretinogram (t-PERG) and the retinal nerve fiber layer (RNFL) thickness in eyes with ocular hypertension (OH) and normal short-wavelength automated perimetry (SWAP).

Methods

In 26 patients with bilateral OH with normal SWAP, and in 26 age and sex matched healthy controls, t-PERG recording and RNFL thickness measurement were performed. Mean deviation (MD) and pattern standard deviation (PSD) of a reliable full threshold 24-2 SWAP were considered. RNFL thickness was determined by OCT3. Monocular PERG were recorded by using a black and white checkerboard pattern (check size 0.9°, contrast 100 %, mean luminance 80 cd/m2) generated on a monitor and reversed in contrast (four reversals per second, 2 Hz) at a distance of 70 cm. Patients had optimal correction at viewing distance; no mydriatic or miotic eye drops were used. Silver/silver chloride skin electrodes were placed over the lower eyelids in the stimulated eye (active electrode) and in the patched eye (reference electrode); ground electrode was in the Fpz scalp. Peak-to peak amplitude of P50 (N35-P50) and N95 (P50-N95) waves, and implicit time of P50, were considered.

Results

Compared to controls, in OH eyes, a reduction of N35-P50 amplitude (2.86?±?1.49 vs. 3.77?±?1.08 microvolts, ?24.1 %, t-test p?=?0.015), of average RNFL thickness (88?±?11 vs. 96?±?10 μm, ?9.5 %, t-test p?=?0.002), and of RNFL thickness in superior (p?=?0.015) and inferior quadrant (p?<?0.001), were found. Multivariate analysis showed that in OH eyes, N35-P50 amplitude was inversely related to intraocular pressure (IOP) (p?=?0.001); no correlation was found between N35-P50 amplitude and MD, PSD, CCT or RNFL thickness.

Conclusions

In OH eyes, both PERG and RNFL thickness changes occur in hypertensive eyes with undamaged SWAP; the correlation of PERG amplitude with IOP, but not with RNFL thickness, suggests that such PERG changes are an effect of the IOP on retinal ganglion cells, rather than a sign of their loss.     

Detection of CMV DNA in peripheral blood leukocytes as a long-range harbinger of CMV disease in HIV-infected patients

The incidence of cytomegalovirus (CMV) end-organ disease can be reduced in AIDS patients by oral ganciclovir. However, the cost effectiveness of this prophylaxis is low. Targeting prophylaxis to patients with the highest risk of developing CMV disease might be useful. Several studies have shown the potential of various polymerase chain reaction (PCR) assays and of the antigenemia assay to identify the subset of patients with a definitely higher risk of developing CMV disease. We studied the CMV viral load using quantitative PCR in the leukocytes and plasma (or serum) of 28 patients in the four years before they experienced a CMV event. We observed rising CMV DNA copy numbers in the patients' leukocytes a year before the event. In contrast, plasma or serum copy numbers rose later and in fewer patients. In a control population of 21 profoundly immunodeficient patients (median CD4+ T cell count: 31/mm 3 ) without history of CMV disease, only five had detectable CMV DNA in the leukocytes, three of whom had barely above-threshold levels. We suggest that, at the present time, leukocyte CMV DNA PCR might represent a sensitive test providing an early warning signal of increased risk of CMV disease. Performing it twice a year might identify patients at risk so that closer monitoring and targeted prophylaxis can be conducted.