Collaborer avec les familles des jeunes adultes avec troubles psychiques débutants : vers un dialogue réflexif ? Illustration de cas

Early intervention programs for young adults with early mental illness value and promote collaboration with families. Partnership is justified in particular by the influence of family tensions on relapse and the importance of redefining ties at this stage of life. However, in practice, implementing interventions with families is still complex and gaps exist between willingness and actual practices. Early intervention programs around the world often favor a psychoeducational approach with families. However, an alternative practice with young adults developed in Finnish psychiatry under the name of “open dialogue” involves a discussion about the process of care during family sessions with the aim of improving it. Inspired by this approach to clinical our case study presents how a reflexive dialogue can be established with families, in the context of observations done within a clinical program for young adults (18 to 25 years) with early mental illness, in order to facilitate collaboration with them. For our case study, reflexive dialogue was implemented through a reflexive interview organized for the family of a 23-year-old single man living in a foster care family and treated after a first psychotic episode. The interview was done in a context of tensions within clinical staff and the family. During this reflexive interview, a member of the clinical staff not directly involved in family sessions collectively interviewed the clinical staff and the families during a semi-structured interview (Example of question for staff: Are there any issues you haven’t talked about yet? Example of question for family: Have you ever felt that you have not been heard by caregivers?). This interview is presented to the families as a way of gathering everyone's impressions of their experiences of family sessions, as freely as possible. This interview is presented as an opportunity to reorient the continuation of therapy by allowing clinicians to better adjust to family expectations. The interview takes place in three stages: (1) The interviewer turns to the caregivers and asks them questions about the family sessions. Family members listen to the answers without intervening (close to the practice of the reflexive team). (2) The interviewer turns to family members and asks them questions. Caregivers listen to their answers without intervening. (3) Family and caregivers are invited to briefly share their impressions of what was said during this interview session. A few weeks after the intervention, quantitative (adaptation of SCORE scale) and qualitative feedback on the usefulness and perception of interview was taken from the clinicians as well as the family. Results suggested that the interview was judged useful by staff and family on several dimensions like positive change in therapeutic relation after reflexive interview. The interview also positively changed the way clinical staff and parents viewed each other within the system of care. Clinical staff saw more resources of parents and parents perceiving a better relationship within clinical staff. Our results seem promising and encourage a more systematic study of reflexive interview effect on collaboration with families.     

A case-control study of risk factors for intussusception among infants in eastern France after the introduction of the rotavirus vaccine

ObjectiveThe objective of the present study was to investigate the risk factors for intussusception (IS) among infants, including vaccination against rotavirus.MethodsCase-control study with systematic inclusion of all infants aged <1 year with suspected IS admitted to emergency departments in the eastern region of France between 1 April 2008 and 31 March 2012. All cases classed level 1 according to the Brighton classification were matched to 4 hospital controls. Two exposure windows were examined; exposure to the first dose of rotavirus vaccine in the 7 and in the 14 days prior to the occurrence of IS.ResultsA total of 115 cases were matched with 457 controls. The average vaccination coverage rate over the 4 years of study was 8.6%. Rotavirus vaccine was not found to be significantly associated with the occurrence of IS in the 7 days (odds ratio (OR) not calculated; p = 0.99) and in the 14 days after administration of one dose vaccine (OR 1.33, 95% confidence interval (CI) 0.14–12.82). Infant formula alone or combined with breastfeeding was associated with an excess risk of IS (OR 2.74, 95% CI 1.10–6.79). A history of gastroenteritis within 2 weeks prior to hospitalisation was also associated with an increased risk (OR 2.24, 95% CI 1.07–4.67).ConclusionOur study indicates that infant formula alone or combined with breastfeeding is a risk factor for IS. A small, non-significant increase in the risk of IS was observed after rotavirus vaccination, although the low vaccine coverage rate likely precluded detection of a significant increase in risk.     

Experiences of nursing home staff using the targeted interdisciplinary model for evaluation and treatment of neuropsychiatric symptoms (TIME) – a qualitative study

Background/Aims: Neuropsychiatric symptoms (NPS) in dementia pose great challenges for residents and staff in nursing homes. The Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms (TIME) has recently in a randomized controlled trial demonstrated reductions in NPS. We explored the participating staff's experiences with the model and how it meets the challenges when dealing with the complexity of NPS.

Methods: Three to six months after the end of the intervention, we interviewed 32 of the caregivers, leaders, and physicians participating in the trial, in five focus groups. We used thematic content analysis.

Results: The analysis yielded two main themes: (1) a systematic reflection method enhanced learning at work; (2) the structure of the approach helped staff to cope with NPS in residents with dementia.

Conclusion: TIME shifts the way of learning for the staff from a traditional to a more innovative and reflection-based learning through a process of learning how to learn at work. The staff's experienced increased coping in their approach to complex problems. Our results emphasise the importance of a structured and biopsychosocial approach to NPS in clinical practice. Future research should explore models for integrating situated learning in daily routines in nursing homes.     

儿童偏头痛验案2则

近年来,儿童偏头痛发病率逐年增高,多数医家从肝阳上扰、瘀血阻络等方面进行论治,张喜莲主任根据儿童"脾常不足、肝常有余"的生理特点,提出采用健脾燥湿豁痰、疏肝行气解郁等方法,辨证治疗儿童偏头痛效果满意。     

Superior trans‐septal approach for minimally invasive mitral valve surgery via right small thoracotomy

Minimally invasive mitral valve surgery (MIMVS), despite its challenges, is not a rare procedure. However, MIMVS via a right small thoracotomy must be performed using long‐shafted surgical instruments and thoracotomy instruments specialized for minimally invasive cardiac surgeries. We have performed 12 cases of MIMVS via right small thoracotomy using the superior trans‐septal approach and secured a surgical visual field that easily allows a finger to reach the mitral valve annulus without using special instruments for minimally invasive cardiac surgery. We named this technique the “drawer‐case technique.” In conclusion, MIMVS via right thoracotomy using the superior trans‐septal approach can be performed easily and safely, similar to mitral valve surgery performed via median sternotomy.     

Le malentendu dans les activités sexuelles à l’adolescence : un signe de sexualité préoccupante ?

ObjectivesThe adolescence corresponds to this existential period when the violence in its creative and destructive functions is the mainspring at the same time and challenge. During this time of passage, the young has to negotiate with himself, his family and the others. Stage of transformation and transfer, revival of multiple psychic conflicts, the adolescence sees the sexuality penetrating the reality of the body. In this context in which the rising sexual activity is associated with a concern, the misunderstanding occupies a central place in the sense where most of the time the protagonists involved in acting him hardly took the opportunity to speak to itself and to get on. Behind a misunderstanding, there are on one side facts and the other one a subject which put them in act.Patients and methodsThe article develops a clinical label involving three adolescents, a boy and two girls. Misunderstandings quickly appear about activity of sexual nature. The excitement gets involved in the fears not without generating of the ambivalence. The mutual incomprehension contains a potential trauma. It is then relevant to intervene without wanting inevitably to define the truth in its material translation of the reality. A type of dense and flexible care gives encouraging results as for the reduction of the traumatisation of a particular event. We move forward stage by stage by proposing times of meeting with a rhythm enough steady and by lending us if necessary as media of expression. Yet it is hardly always well-to-do to act not in the haste but with density and speed in the interest of some of the others. It is essential to take into account at the same time relational stakes, their impacts on the individualities, and the psychic dimensions appropriate to every protagonist. A collective and personal historian can develop in these testing moments of crisis on basis of an intervention such as sketched here, by considering repercussions at the level of the socio circle of acquaintances.ResultsThe approaches which establish themselves on the only reality of the behaviour risk to evacuate the subject which puts the qualified act of worrying. For us we suggest dreading the subjective dimension by examining the question of the sexuality from the point of view of the functioning of a personality. In other words, the question is not only of knowledge which is the act which was put, but to know which committed it. We thus watch to construe the subjective impact of the act, by reminding that the human being becomes established as subject of his speech and as agent of his act. The misunderstanding also constitutes an original media of meeting of the teenager in question. We propose a categorization of worrisome sexual activities by underlining that, in number of scenarios, the young person shows elements of several categories: a/the young people in sexual life without restraint; b/the young people confronted with the constraint of the anxiety; c/the young people led by an intense need for love; d/the young people committing sexual abuses; e/the young people showing a perversion. Besides, we shall not evoke rare disturbing sexual activities put aside by the young people in the psychotic functioning. The care leans on two concepts-keys, on one hand, the succession of two different phases, that are the evaluation and the treatment and on the other hand, the complementarity of several epistemology as well as the work in network. We advocate the establishment of a partnership envelope based on the collaboration and the respect of the principles of the shared secret.ConclusionsThe misunderstanding can reveal a worrisome sexual activity in the adolescence. Indeed let us limit the current trends “to tax” any sexual act of aggression, and his author of “abuser”, and the addressee to act him of “victim”! To limit, we determine what belongs to the physical, sexual exploration, including the consensus of the protagonists, what goes out again from the pathology. The distinction is essential at the risk otherwise to stigmatize certain young people in full constructive run-up by gathering in a single troop of the different profiles from each other. The misunderstanding represents a beautiful opportunity of meeting of a young person in the inviting to a correct interpretation of the facts, by taking into account the place they occupy in the psychic and relational functioning.