Pathologies ophtalmologiques de l’enfant cérébrolésé et du polyhandicapé

For a long time, ophthalmologic and neuro-ophthalmologic pathologies have not been explored enough in polyhandicapped children. However, vision makes up for an important part in cerebral activity and in child construction. After having located the ophthalmologist and orthoptist contribution, we tried, following the anatomophysiological way of the visual impulse, to describe any pathologies and practical therapeutic behaviors. Those are described concerning eyes, optical pathways, cerebral visual functions, ocular motility and some specific situations of the disabled child. The best possible knowledge of these pathologies is essential to a therapeutic and educative intervention, respecting the child as a whole.     

Place de l’électroencéphalogramme dans l’état de mal épileptique

Recordings of the electroencephalogram (EEG) play a major role in the management of patients with status epilepticus (SE). The EEG contributes to the diagnosis of SE, can be used to identify differential and syndromic diagnoses, and sometimes provides the etiologic diagnosis. EEG is helpful in monitoring therapeutic management and is an essential component of the follow up. The interpretation of the EEG in a patient with refractory SE is difficult, requiring clinical experience in this domain. We discuss the different modalities of EEG recording and their indications in emergency situations.     

Une méningovascularite infectieuse de Lyme révélée par des accidents ischémiques cérébraux successifs

Introduction

Infectious vascularitis is an unusual cause of ischemic stroke (IS). We report a case of Lyme meningovascularitis complicated with multiple IS.

Case report

A 64-year-old man, without any cardiovascular risk factor, was admitted for a right hemiparesia with a left thalamic hypodensity on the initial cerebral CT scan. No cause for this presumed IS could be identified. Later, the patient developed cognitive impairment and a bilateral cerebellar syndrome. Multiple infarcts and multiple intracranial stenosis were seen on cerebral MRI with magnetic resonance angiography (MRA). Cerebrospinal fluid tests showed meningitis and positive Lyme serology with an intrathecal specific anti-Borrelia antibody index. Antibiotic treatment was followed by good biological and partial clinicoradiological outcome.

Conclusion

The diagnosis of Lyme neuroborreliosis should be entertained as a possible cause of IS in highly endemic zones.     

Milnacipran et venlafaxine à posologie flexible (jusqu’à 200 mg/j) dans le traitement ambulatoire des épisodes dépressifs majeurs modérés à sévères de l’adulte : étude exploratoire de 24 semaines, randomisée en double insu

Introduction

Serotonin (HT) and noradrenaline (NA) reuptake inhibitors (SNRIs) are commonly used as first line treatment of major depressive disorders (MDD). As compared to tricyclic antidepressants, they have proved similar efficacy and better tolerability. Milnacipran (MLN) (Ixel^®) and venlafaxine (VLF) (Effexor^®) are two SNRIs pharmacologically differing by their NA/HT ratio of potency: 1:1 and 1:30, respectively.

Objectives

To investigate the efficacy and safety/tolerability of MLN and VLF administered at flexible doses (100, 150 or 200 mg/day) for 24 weeks (including 4 weeks of up-titration) in the outpatient treatment of adults with moderate-to-severe MDD.

Design

Multicentre, randomised, double blind, 2-parallel-arm, 24-week exploratory trial conducted in France by 50 psychiatrists.

Diagnosis and main inclusion criteria

Male or female outpatients, aged 18 to 70, meeting the DSM-IV-TR and related MINI criteria for recurrent, unipolar, moderate-to-severe MDD, with neither psychotic features nor severe suicidal risk. A Montgomery-Asberg depression rating scale (MADRS) score ≥ 23 was required at inclusion.

Treatment schedule

Patients were randomised to receive either MLN or VLF (1:1 ratio) for 24 weeks in double-blind conditions. Regardless of the treatment received, the following dosing schedule was applied: during the initial 4-week up-titration phase, the dosage was progressively increased from 25 mg/day (qd administration) to 150 mg/day (bid administration). At week 4, the dosage was either maintained at 150 mg/day, or adapted to 100 or 200 mg/day, based on the investigator's clinical judgement. At any time during the 20 following treatment weeks, the dose could be lowered for safety concerns until a minimal threshold of 100 mg/day. From Week 24, the dosage was decreased by 50mg/day every five days. After randomisation, eight assessment visits were organised at 2, 4, 6, 8, 12, 18, 24 weeks, and at study end (after the 5–15 days of down-titration and 10 days free of treatment). Efficacy evaluation ratings included the MADRS and global disease severity (CGI-S) total scores. Rates of MADRS response (reduction of initial score ≥ 50%) and remission (score ≤ 10) were calculated at Week 8 and Week 24 in the full analysis set as well as in the subgroups of patients with depressive disorder of severe DSM-IV intensity and with a MINI evaluation of suicidal risk (rated as required ‘moderate’ at the worst).

Statistical analysis

Standard distribution statistics (including mean and standard deviation [S.D.]) of scores and their changes from baseline, were calculated using the observed-case (OC) approach at all assessment times for the MADRS score, and the last-observation-carried-forward (LOCF) at 8 and 24 weeks for both MADRS and CGI-S scores. MADRS response and remission rates at 8 and 24 weeks were calculated using the LOCF approach by normal approximation of the binomial distribution. Bilateral exploratory statistical tests at 5% significance level were performed for results at 8 and 24 weeks of: (i) MADRS score changes from baseline, based on the score progress at each visit (mixed model for repeated measurements [MMRM]), and (ii) global MADRS response and remission rates (Chi²).

Results and patients

A total of 195 patients were randomly assigned MLN (n = 97) or VLF (n = 98) and 134 (68.7%: 61.9%/MLN and 75.5%/VLF) completed the trial. At the end of the up-titration, patients received 100 mg/day (11.4%/MLN, 10%/VLF), 150 mg/day (30.4%/MLN, 43.8%/VLF), or 200 mg/day (58.2%/MLN, 46.3%/VLF). Totals of 177 patients (90/MLN and 87/VLF) and 181 patients (90/MLN and 91/VLF) were analysed for efficacy and safety, respectively. Treatment groups were similar for baseline characteristics except a higher proportion of MLN patients with a severe depressive episode (63.3% versus 54%).

Results and efficacy

MADRS score (mean [S.D.] initial score: 31 [4.5]) progressively decreased all along the treatment course and similarly in both groups (Week 8-OC : –18.8 [7.7]/MLN and –18.6 [7.3]/VLF, p_MMRM = 0.95 ; Week 24-OC : −23.1 [7.8]/MLN and –22.4 [7.3]/VLF, p_MMRM = 0.37 ).At week 8-LOCF, MADRS response rates were similar in both groups (64.4%/MLN, 65.5%/VLF, p_chi2 = 0.88) as well as remission rates (42.2%/MLN, 42.5%/VLF p_chi2 = 0.97). At week 24 they remained non clinically and statistically different between groups (response rates: 70%/MLN, 77%/VLF, p_chi2 = 0.29; remission rates: 52.2%/MLN, 62.1%/VLF, p_chi2 = 0.19). In both “severe depressive episode” and “MINI mild or moderate suicidal risk” subgroups (n = 104 and 75, respectively), response and remission rates were non clinically different at both time points, however in the “MINI mild-to-moderate suicidal risk” subgroup, MLN tended to be more rapidly active (remission rate at week 8-LOCF: 44.7%/MLN, 35.1%/VLF). The changes in CGI-S were also indicative of a significant improvement of the global illness severity with both treatments.

Results and safety/tolerability

The tolerability profile of both drugs was in line with their pharmacological activity. About 70% of patients in both groups experienced at least one adverse event (AE). In both groups, the most common AEs were nausea, dizziness, headache and hyperhidrosis, and, in the male patients, genito-urinary problems: orgasmic disorders (VLF only) and dysuria (MLN only). These AEs were mostly responsible for definitive treatment discontinuation for tolerability concerns. None of the 6 serious adverse events (SAEs) on MLN and 4 of the 8 SAEs on VLF were related to the test drug.

Conclusion

MLN and VLF at flexible doses up to 200 mg/day globally exhibited similar efficacy and tolerability profiles in the long-term treatment of adults with MDD.     

Impact du niveau d’activité physique sur l’alexithymie et le coping dans une population de plus de 40 ans atteinte de sclérose en plaques : une étude pilote

Introduction

The aim of this study was to evaluate the impact of physical activity on alexithymia and coping strategies among people with multiple sclerosis aged over 40. The hypotheses were that physical activity should have a protective effect on alexithymia, and more particularly, on “emotional identification” and could influence coping strategies because it can be considered as a distractive coping strategy.

Methods

Thirty-seven patients aged 40 years or older were asked to complete a form including an identification sheet and standardized questionnaires: the Bermond-Vorst Alexithymia Questionnaire (version B), the Coping with Health Injuries and Problem Questionnaire, the Fatigue Impact Scale, and the Hospital Anxiety and Depression Scale.

Results

The participants with a high or moderate level of physical activity used “information research” as a coping strategy better than those who had a lower level of physical activity. They also analyzed their emotions better. The results revealed an association between these variables and anxiety, depression and fatigue.

Discussion

This study provides insight for future research about the impact of physical activity on multiple sclerosis.