Effet du traitement antirétroviral sur les manifestations électroencéphalographiques et otoneurologiques précoces de l''infection à VIH et signification pronostique des perturbations constatées

Electrophysiologic tests may be abnormal in asymptomatic HIV-1-infected individuals. Our study was aimed at determining whether these findings have a prognostic value and could be corrected by antiviral treatment. In 18 patients, followed for 34 or 43 months, these findings were not progressive. Only one patient developped Aids dementia complex (ADC). Three have died (one with normal, two with abnormal tests at baseline). To study the effect of antiviral treatment, another group of seven asymptomatic patients was included into a cross-over double-blind study with either eight weeks zidovudine or eight weeks placebo, separated by eight more weeks without treatment. Electrophysiological evaluation was also performed in a group of 15 patients before antiviral therapy with zidovudine or didanosine was started and again after a mean of three and 13 months treatment. Results did not suggest that treatment reverses early electroencephalographic and otoneurological changes seen in HIV-1 infection.     

Explorations électrophysiologiques dans les périnées descendants chez la femme

Seventy five female patients (mean age: 55 ± 13 years) were included into the study. Electromyography of the perineum with study of the intramuscular activity of the external anal sphincter was done and measures of the sacral reflexe latency were obtained by stimulation of the cavernous nerve of the clitoris, recording in the external anal sphincter muscle. Neurogenic syndromes of pudendal nerve either isolated or associated with muscular disorders have been shown to be correlated with descending perineum. In our study, we investigated whether a history of obstetrical or surgical interventions is related to the occurence of this syndrom. We did not find any significant relationship.     

Le botulisme alimentaire au Maroc, à propos de 15 cas. Valeur diagnostique de l’électrophysiologie

Introduction

Botulism is a rare but serious disease, which affects the peripheral autonomous nervous system, potentially with a fatal outcome. In Morocco, botulism is exceptional.

Patients and method

This was a prospective analysis of the epidemiological, clinical, neurophysiological and toxicological features of 15 cases of food-borne botulism identified among a series of 45 highly suspect cases collected in Morocco during an epidemic in August 1999.

Results

The 15 patients (eight females, seven males) included in the protocol were aged 3 to 49 years (average 18.8 years). One-third of the cases occurred in a familial context. The clinical presentation was typical and complete in nine cases; respiratory failure was noted in four patients. Botulinum toxins were found in nine cases. Outcome was less than favorable, with total recovery in seven cases, persistence of motor sequelae in three and death in five. Electrophysiological investigations showed an incrementing response at high frequency in 73.3%, a decrement at lower frequency in 60% and low motor amplitudes in 93%. These findings constituted a very sensitive and specific triad for botulism diagnosis.

Discussion/conclusion

These findings illustrate the gravity of botulism and the important diagnostic value of neurophysiological results, especially incrementation, which can provide a very pertinent diagnostic contribution, especially in seronegative patients.     

Résisteur de starling et stabilité du couple sommeil-ventilation

The upper airway can be described as a collapsible segment (the pharynx) interposed between two rigid bony (the cavum) or cartilaginous (the trachea) segments. Due to this structure, the pharynx behaves as a collapsible tube, in which airflow does not depend on the downstream pressure, but is limited to a maximum value which depends only on the upstream pressure and on the pressure surrounding the collapsible segment; itthis behavior, known as a Starling resistor can be modeled by the waterfall effect. Thus, the upper airways can be in three different conditions: an occluded condition, in which no flow is possible, a patent condition, in which flow depends on the difference between upstream and downstream pressures (according to Poiseuille 's law), and a situation in which flow is limited. The behavior of the upper airway is largely dependent on its anatomic structure, but functional factors play a critical role. Among these sleep state is both a determinant of the collapsibility of the pharynx, and determined by the simulation of upper airway mechanoreceptors whose activity depends on the activity of respiratory muscles. Thus the interplay of three factors: ventilatory drive, upper airway collapsibility, and arousal threshold can predict most of the situations of stable and unstable ventilatory behavior during sleep. The level of the arousal threshold governs the stability of the ventilatory pattern, as it determines whether a combination of flow, respiratory effort, and blood gases can be maintained or is interrupted by an arousal.     

L’éthique de la recherche en psychiatrie adulte

Medical research aims to improve the human condition by developing a body of knowledge valid and reliable. The history of medicine over the centuries, however, was marked by numerous scandals showing the possible misuse of research when it is not framed with an ethical, or the law. The ethical debate is ongoing and researchers must continually examine their practices. In psychiatry, the object of research is a human being made vulnerable by his trouble. The aim of this article is examine the theoretical foundations of ethic in research on human being. It is therefore a reflection of the true significance of this concept, its history, its principles and particularities in the field of psychiatry.     

Mémoire émotionnelle du soi

Emotion shapes autobiographical memory (AM) by tagging events that are relevant for the narrative self, which may be viewed as a hierarchical network of interconnected goals. Subsequent AM retrieval is a reconstruction process that grounds the self by providing coherent narratives organized to elicit a sense of identity across the time. The lateral and medial prefrontal cortices underlie reconstruction and self-referential processing, respectively, whereas the lateral and medial temporal cortices underlie semantic and episodic aspects, respectively. Additionally, the posterior cortical midline structures and the amygdala are involved in visual and emotional aspects, respectively. These regions have been found to display aberrant functioning in major depression. Accordingly, major depression is associated with impairments of AM retrieval combining mood-congruency, overgenerality, intrusive memories and third-person visual perspective.     

Efficacité et tolérance du cyclophosphamide dans le traitement de fond des formes progressives de la sclérose en plaques

Introduction

Cyclophosphamide (CPM) is used empirically in the treatment of progressive multiple sclerosis. The purpose of this study was to evaluate its efficacy in naive patients with progressive multiple sclerosis.

Patients and methods

Thirty-one patients were retrospectively included (17 secondary multiple sclerosis, 14 primary progressive multiple sclerosis), and received infusions of CPM (600 mg/m²) every eight weeks, for 18 months. Evaluation was based on time to EDSS progress.

Results

Among patients with secondary progressive multiple sclerosis, 94% were stable or improved at six months, 77% at 12 months, and 75% at 18 months. The same result was reported in 69.2% of primary progressive multiple sclerosis at six months, 64% at 12 months, and 55.5% at 18 months. We found no difference between the two groups.

Conclusion

Our results suggest that the CPM is efficient in progressive multiple sclerosis; however, its place must be reconsidered before establishing an international consensus for treatment; open label studies are needed to validate the present findings.     

Insight et capacité à consentir au soin et à la recherche : étude exploratoire et points de vue éthiques

In recent years, there has been a growing awareness that the process of obtaining informed consent is central to ethical research and clinical practice. Many studies have focused on the ability to consent for patients suffering from severe mental disorders such as schizophrenia. Several studies have focused on the association between impaired capacity to consent (to treatment or research) and diagnosis or symptoms. But one of the most important features of schizophrenia, the lack of insight has not been extensively studied in relation to capacity to consent. The aim of this study was to explore the relationship existing between the competence to consent and the level of insight in patients suffering from schizophrenia in a cross-sectional study. Participants included 60 outpatients with DSM-IV schizophrenia. Measures included the MacArthur Competence Assessment tool for Treatment (MacCAT-T), the Scale to Assess Unawareness of Mental Disorder (SUMD) and psychopathology rating scales including the Positive and Negative Syndrome Scale (PANSS). Our results showed that “understanding” dimension of MacCAT-T is not correlated to insight. However, a systematic negative correlation was observed between the MacCAT-T “Appreciation” and “Reasoning” dimensions and the five SUMD dimensions. We hypothesise that this strong correlation could be mediated by cognitive disorders in schizophrenia. After such results, prospective studies should be developped evaluating the courses of insight and capacity to consent during the illness and the links with cognitive deficits.     

Newborns with hyperbilirubinemia: usefulness of brain stem auditory response evaluation

We describe brain stem auditory evoked potentials (BAEP) obtained in 48 full-term newborns (20 boys, 28 girls) presenting with high serum total bilirubin concentration (from 238 to 442 mM) without Rhesus or group A, B, O factors incompatibility. Recordings were performed on the 3rd day of life and repeated 5–7 days post-appropriate therapy with photostimulation and exchange transfusion (when bilirubin concentration had decreased below 136 mM). Supplementary recordings were performed 3, 6 and 12 weeks later in order to assess test-retest reliability of components. Mean values of BAEP latencies were compared with those obtained in 40 age-matched control subjects using the same recording procedures. At first recording session (on the 3rd day), latencies of waves III and V obtained in hyperbilirubinemic patients were significantly increased as compared with records in control subjects. Recordings performed 5 to 7 days post-therapy and during subsequent recording sessions showed no significant differences between patients and control groups. Serial neuropsychological evaluations obtained over a 3-year follow-up showed no subsequent neurodevelopmental abnormality for all patients. These findings suggest that hyperbilirubinemia can alter central neurotransmission in auditory brain stem pathways, but this modification is only transient.

Résumé

Nous avons enregistré les potentiels évoqués auditifs du tronc cérébral (brain stem auditory evoked potentials, BAEP) de 48 nouveau-nés (20 garçons, 28 filles). Les sujets avaient une concentration sanguine élevée en bilirubine totale (de 238 à 442 mM) et ne présentaient ni incompatibilité du facteur rhésus, ni incompatibilité de groupe sanguin (A, B, O). Les enregistrements ont été effectués au 3^e jour de vie, puis répétés aux 5^e et 7^e jours de vie après traitement par photostimulation et exsanguinotransfusion (lorsque la concentration de bilirubine était inférieure à 136 mM). Des enregistrements effectués 3, 6 et 12 semaines plus tard ont permis de vérifier la reproductibilité des BAEP. Les valeurs moyennes des latences des BAEP ont été comparées à celles obtenues dans un groupe témoin de 40 sujets. Au cours de la première évaluation, les latences de la 3^e et de la 5^e onde enregistrées chez les enfants présentant une hyperbilirubinémie étaient plus élevées que chez les sujets témoins. Les enregistrements effectués par la suite ont montré que les latences des composantes des BAEP étaient identiques dans les deux groupes. Les évaluations effectuées au cours des trois années suivantes ont mis en évidence l'absence de désordres neuropsychologiques. Cette étude montre que l'hyperbilirubinémie peut modifier la neurotransmission centrale, mais uniquement de façon transitoire.     

Impact d’une campagne de sensibilisation sur le cancer sur un échantillon de femmes en traitement pour un premier cancer du sein

In 2007, the French National Cancer Institute initiated a cancer communication campaign entitled “We are two million ordinary heroes”. Aims of this study were to investigate perceptions about this campaign, for 34 women treated for breast cancer. Triangulation of the reports from narratives and assessment of psychological variables ensures better validity of the data. Three psychological identification processes have been identified: identification with the hero character with a value of emotional repression; adherence to content “ordinary” with low-level of perceived self-efficacy; no identification in response to a double-bind message, with sense-making process about traumatic event. These findings underscore the need to promote communication health campaigns taking into account possible effects of media discourse on individuals and families struggling with cancer.     

Les structures de réhabilitation : du secteur au réseau

Patients suffering from schizophrenia usually stay excluded from the society despite the development of the psychiatric system for the last 50 years. To look for root cause and to consider the organization to set around the concept of the fourth paradigm, it appears relevant to cross local experience gained from a team of psychiatric practitioners to theoretical thinking.     

Phobie sociale dans l’anorexie mentale : évolution au cours des soins

Context

The links between anorexia nervosa (AN) and anxiety disorders, and particularly social phobia, are little known. However, social phobia occurs frequently in AN. Some studies have shown reduction in anxious and depressive symptomatology in AN with re-nutrition. But, to our knowledge, no work has examined the evolution of social phobia symptoms during re-nutrition in AN.

Objectives

To specify the links between AN, nutritional state, and social phobia.

Method

The population consisted of 2 samples and the analysis was conducted using the SPSS 11.5. Sample 1 (N = 24 AN) was evaluated on admission and on leaving the hospital. Our evaluation used the body mass index (BMI), the Liebowitz scale, the Mini International Neuropsychiatric Interview (MINI), and the Yale-Brown Obsessive Compulsive Scale for Eating Disorders scale (Y-BOCS-ED) respectively to evaluate or diagnose the state of malnutrition, social anxiety symptomatology, social phobia in Diagnostic and Statistical Manual-4 (DSM-IV) and anorexic symptomatology. Sample 2 (N = 60) was assessed at the end of the hospitalization and then 6, 12 and 18 months later. We used the BMI, Liebowitz scale, MINI, and Eating Disorders Inventory (EDI) to assess anorexic symptomatology. In addition, the Morgan-Russell outcome assessment schedule (MR schedule) was used to assess the total clinical state of the patients.

Results

Social anxiety symptomatology and actual diagnosis decreased throughout the treatment. However, regardless of the point at which the patient received care, there was no correlation between social phobia and nutritional state, as indicated by BMI. A correlation existed between social phobia and AN symptomatology, and between social phobia and total clinical state, during the out-patient care.

Conclusion

A component of AN–social phobia comorbidity is still questionable. Is it linked to the clinical state of the subjects (question of an additional effect of under nutrition and cognition), or even to AN? Others indicators of under nutrition are of interest and warrant further evaluations. We therefore feel that a diagnosis of social phobia can only be confirmed after an acute state of AN, thus allowing for preferential treatments. Others studies must be conducted in order to continue to explore the links between social phobia and AN.     

Le comportement d’observance des patients atteints de schizophrénie : impact du diagnostic et du traitement. Analyse phénoménologique de trois attitudes

The aim of this study is to analyze the different characteristics of three patient clusters defined according to their relationship toward their disease. Based on the 40 patients collected data, we were able to identify three patient groups: 23 patients were qualified as “active” as they showed a more collaborative participation in career venues and higher acceptance of comprehensive treatment plans (57.5 %). Seven patients were qualified as “passive” as they had less autonomy and therefore were less concerned with the treatment modalities (17.5 %). Ten patients were qualified “ambivalent” as they had a more conflicted understanding and insight of their disease, of their careers and their family dynamics (25 %). “Active” patients had a higher level of understanding of their diagnosis, were more aware of prescribed treatments and of the negative consequences of poor compliance. “Passive” patients were more willing to learn about their diagnosis, while having a significantly lower baseline knowledge of it, were more often prescribed an atypical neuroleptic and reported higher satisfaction with their medical treatment. “Ambivalent” patients had a higher propensity for disagreeing with the negative consequences of their disease, were more often prescribed two classic neuroleptics, reported higher rate of self-discontinuation of treatment and were overall less satisfied with their treatment. It appears that the disagreement with the understanding of the disease and its seriousness has a major impact on the acceptance of the treatment modalities and leads to reduced adherence to treatment plan.     

Le soin en famille d’accueil : théories du « care » et quotidienneté

Receiving people in situation of psychological vulnerability in foster families implies, beside a shared everyday life, a concern for these persons and for their well-being, in other words a form of care, different from cure treatments. The current development of “theories of care”, in the field of moral and political philosophy, helps to specify the dimensions of care, including its intrinsic ethical dimension. These ones turn out to be relevant in the context of foster families. People take care not only of other people, but also of the shared and everyday world in which they live together. This care of the shared world is to be itself shared.     

Insight et neuro-imagerie : l’apport de l’étude des réseaux du repos

Insight, in the field of psychiatry, can be seen as a complex phenomenon involving the ability to recognize one's own mental illness and the need for a treatment, but also to attribute a cause to various symptoms and life events. Patients with schizophrenia appear to have a lack of insight, leading to a poor outcome. Several theoretical models postulate a link between insight on the one hand, and cognitive (executive and autobiographical) dysfunctions on the other hand. In the past decade, large amounts of work have been dedicated to a particular network: the Default-Mode Network. This network seems to support the spontaneous mental activity of a subject at rest. In particular, its activation seems to be elicited by thoughts dealing with self-awareness. In a functional Magnetic Resonance Imaging study, we highlighted several network alterations in patients with schizophrenia, and one of these seems to have a relationship with insight. In the light of these results and the existing literature, we propose a conceptual framework of lack insight in schizophrenia with implications for future research.