Family burden and care participation: A test-retest reliability study of an interview instrument concerning families with a severely mentally ill family member

Objective: Many youngsters with mental health problems are not referred to mental health clinics. Parents play an important role in the referral process of youngster to mental health clinics. The main aim of this study was to explore the role of the parent–child relation for referral of adolescents to outpatient psychiatric clinics. Method: Employing a cross-sectional design, we compared a referred sample of 39 adolescents in outpatient psychiatric treatment with a non-referred matched control sample of 39 adolescents. The Parental Bonding Instrument and Youth Self-Report were employed to assess the characteristics of these two population groups. Results: Adolescents referred to Norwegian mental health clinics for mental health problems report more perceived care from mothers and a trend of more care from fathers compared with non-referred controls matched on level of mental health problems, age and gender. Implications of the finding for the role of parents on referral of adolescents to mental health clinics and for treatment compliance are discussed.     

Does a neurology department need its own intensive care unit?

Zusammenfassung Kurze Stellungnahme zur Frage, ob eine Neurologische Klinik in einem Großkrankenhaus ihre eigene Überwachungs- und Intensiv-Pflege-Station haben soll. Die Frage wird bejaht und diese Entscheidung begründet.     

Quand dire,c’est soigner

The discourse in the care relationship bridges the gap between the human relationship and a course of care, allowing patients to accept it and sometimes to take on the hardship. This discourse allows technical exchanges between doctors, caregivers, and patient. If the conditions for a deep listening and reciprocal empathy are present, discourse is the booster allowing the construction of a human relationship, which keeps and improved the professional framework. This construction is not always done, often because of the institutional operating conditions. Communication on care, limited to interactions between people, replaces then a human relationship that has failed to presentified itself. To build the relationship in care, caregivers and patients can only rely here on their openness to human people, their theoretical humility and respectful of others, as well as the crucible of common knowledge supported by the institutional environment and the scientific framework. The discourse of caregivers and patient aims to homogenize their representations of the disease and to cultivate mutual trust in order to build a relationship in care lasting over time and for both, memorizing key moments on the emotional or the cognitive level during the care circuit. It develops and allows to share their common memories.     

Vulnerability factors in anxiety: Strain and sex differences in the use of signals associated with non-threat during the acquisition and extinction of active-avoidance behavior

Rats that exhibit a behaviorally inhibited temperament acquire active-avoidance behaviors quicker, and extinguish them slower, than normal outbred rats. Here we explored the contribution of stimuli that signal periods of non-threat (i.e. safety signals) in the process of acquiring active-avoidance behavior. Utilizing a discrete lever-press escape-avoidance protocol, outbred Sprague-Dawley (SD) rats and inbred, behaviorally inhibited, Wistar-Kyoto (WKY) rats were tested under conditions where a flashing light was either presented or not during periods of non-threat (the inter-trial interval, ITI). For males, we found the absence of the ITI-signal slowed the acquisition of avoidance behavior selectively in WKY rats. However, extinction of the avoidance behavior was not influenced by training with or without the ITI-signal; WKY males extinguished slower than SD males. For females, the presence of the ITI-signal did not affect acquisition in either strain. However, after training with the ITI-signal, females of both strains extinguished quicker in its absence than in its presence. In order to determine if facilitated acquisition of avoidance learning in male WKY rats was due to a paradigm-independent influence of the visual stimulus used as ITI-signal upon associative learning, we conducted eyeblink conditioning in the presence or absence of a similar visual stimulus. No differences in acquisition, as a function of this visual stimulus, were observed within the male WKY rats, but, as was observed in avoidance learning, male WKY rats extinguished slower than male SD rats. Thus, avoidance susceptibility for male WKY rats may be tied both to the presence of non-threat signals as well as a resistance to extinguish Pavlovian-conditioned associations. Female susceptibility to resist extinguishing avoidant behavior is discussed with respect to the possible role of stimuli serving as occasion setters for threat contexts.     

Vulnerability factors in anxiety determined through differences in active-avoidance behavior

The risk for developing anxiety disorders is greater in females and those individuals exhibiting a behaviorally inhibited temperament. Growth of behavioral avoidance in people is a significant predictor of symptom severity in anxiety disorders, including post-traumatic stress disorder. Using an animal model, our lab is examining how the process of learning avoidant behavior may lead certain individuals to develop anxiety. Here we examined whether the known vulnerabilities of female sex and behaviorally inhibited temperament have individual or additive effects upon the acquisition of an active-avoidance response. A discrete trial lever-press escape–avoidance protocol was used to examine the acquisition of behavioral avoidance in male and female Sprague–Dawley (SD) rats and behaviorally inhibited inbred Wistar–Kyoto (WKY) rats. Overall, WKY rats of both sexes were indistinguishable in their behavior during the acquisition of an active-avoidance response, exhibiting quicker acquisition of reinforced responses both between and within session compared to SD rats. Further WKY rats emitted more non-reinforced responses than SD rats. Sex differences were evident in SD rats in both the acquisition of the reinforced response and the emission of non-reinforced responses, with SD females acquiring the response quicker and emitting more non-reinforced responses following lever presses that led to an escape from shock. As vulnerability factors, behavioral inhibition and female sex were each associated with more prevalent reinforced and non-reinforced avoidant behavior, but an additive effect of these 2 factors was not observed. These data illustrate the importance of genetics (both strain and sex) in the assessment and modeling of anxiety vulnerability through the acquisition of active-avoidance responses and the persistence of emitting those responses in periods of non-reinforcement.     

Sustained high plasma plasminogen activator inhibitor-1 levels are associated with severity and mortality in septic patients

Background

Higher plasma plasminogen activator inhibitor-1 (PAI-1) levels have been reported in septic patients. However, some questions remain unanswered, such as whether there is an association between plasma PAI-1 levels and sepsis severity and mortality, and inflammation state during the first week.

Methods

Multicenter, observational and prospective study carried out in six Spanish Intensive Care Units of 260 patients with severe sepsis. Circulating levels of PAI-1 and tumour necrosis factor (TNF)-α were measured at day 1, 4 and 8. End-point was 30-day mortality.

Results

Nonsurviving septic patients (n = 89) presented higher PAI-1 levels than surviving (n = 171) at day 1 (58.4 (33.3-83.8) vs 36.5 (21.1-62.5) ng/mL; p < 0.001), 4 (34.0 (14.7-53.3) vs 16.2 (10.2-27.4) ng/mL; p < 0.001) and 8 (30.6 (16.2-47.8) vs 18.9 (10.4-29.5) ng/mL; p = 0.004). We found a positive correlation of PAI-1 levels with SOFA, lactic acid, aPTT, INR and TNF-α, and negative with platelet count at day 1, 4 and 8. Logistic regression analyses showed that PAI-1 levels at day 1 (p < 0.001), 4 (p < 0.001) and 8 (p = 0.001) were associated with 30-day mortality. On ROC curve analysis to predict 30- day survival, the area under the curve of PAI-1 levels at day 1, 4 and 8 were 0.65 (95% CI = 0.58-0.72; p < 0.001), 0.69 (95% CI = 0.60-0.78; p < 0.001) and 0.65 (95% CI = 0.54-0.75; p = 0.005) respectively.

Conclusions

The most interesting findings of our study, to our knowledge the largest series reporting PAI-1 levels during follow-up in septic patients, were that plasma PAI-1 levels during the first week were associated with inflammation, severity and mortality.     

Diurnal variation of soluble CD40 ligand in patients with acute coronary syndrome. Soluble CD40 ligand and diurnal variation

Introduction

We sought to investigate whether day-night variations occur in the concentration of circulating soluble CD40 ligand in patients with acute coronary syndrome, as this may have practical implications.

Materials and Methods

We assessed 70 consecutive ST-segment elevation myocardial infarction patients admitted into the Coronary Care Unit and 50 control subjects. Each subject was studied under strictly controlled light/dark conditions. Blood samples were drawn at 09:00 h (light phase) and 02:00 h (dark phase). Nocturnal blood samples were drawn by a trained nurse, with the help of a minute torch with a dim red light in order to avoid any direct lighting on the patient during sleep. The soluble CD40 ligand was measured using a commercially available ELISA.

Results

Soluble CD40 ligand levels showed no diurnal variations in control subjects. In the ST-segment elevation myocardial infarction group, however, soluble CD40 ligand concentration (pg/mL) in the light phase was significantly higher than that in the dark phase (167.3 ± 63.2 vs 118.9 ± 48.3 pg/mL, p < 0.001).

Conclusions

The study shows for the first time the existence of diurnal variations in soluble CD40 ligand levels in ST-segment elevation myocardial infarction patients, which indicates the need for standardizing the time of blood sampling for the assessment of this molecule, at least in studies involving ST-segment elevation myocardial infarction patients.     

Serum soluble CD40 Ligand levels are associated with severity and mortality of brain trauma injury patients

Background

Serum soluble CD40 Ligand (sCD40L) levels, which exhibit prothrombotic and proinflammatory properties, have not been studied in patients with traumatic brain injury (TBI). Thus, the objective of this study was to determine whether serum sCD40L levels are associated with severity and mortality in patients with severe TBI.

Methods

This was a prospective, observational and multicenter study carried out in six Spanish Intensive Care Units. Patients with severe TBI defined as Glasgow Coma Scale (GCS) lower than 9 were included, while those with Injury Severity Score (ISS) in non-cranial aspects higher than 9 were excluded. Serum levels of sCD40L were measured on the day of TBI. Endpoint was established in 30-day mortality.

Results

We found higher serum sCD40L levels (P < 0.001) in non-surviving TBI patients (N = 27) than in survivor ones (N = 73). Logistic regression analysis showed that serum sCD40L levels were associated with 30-day mortality (OR = 1.58; 95% CI = 1.12-2.21; P = 0.008) controlling for APACHE-II score and computer tomography findings. The area under the curve (AUC) for serum sCD40L levels as predictor of 30-day mortality was 0.79 (95% CI = 0.70-0.86; P < 0.001). Survival analysis showed that patients with serum sCD40L levels higher than 2.11 ng/mL presented increased 30-day mortality than patients with lower levels (Hazard ratio = 9.0; 95% CI = 4.25-19.27; P < 0.001). We found an association between serum sCD40L levels and APACHE-II (rho = 0.33; P = 0.001), and GCS score (rho = -0.21; P = 0.04).

Conclusions

To our knowledge, this is the first study reporting data on serum sCD40L levels in patients with severe TBI. The most relevant and newer findings of our study are that serum sCD40L levels in non-surviving patients with severe TBI are higher than in surviving ones, and that there are an association between serum sCD40L levels and TBI severity and mortality.     

Siblings in foster care: Success and failure

This article reports on a retrospective study of 59 joint placements of siblings in foster homes, involving a total of 137 children. An overall picture is presented of the agencies' considerations in making these placements. The number of prematurely terminated placements in this group amounted to 14 (23.7%). Several factors that appear related to premature termination are discussed.Frits Boer is a university lecturer in the Department of Child and Youth Psychiatry at the University of Leiden in the Netherlands and works as a child psychiatrist at the Academic Center for Child and Adolescent Psychiatry Curium in Oegstgeest. Stella Spiering is developmental psychologist in Rijswijk, the Netherlands.     

Évaluation du recours au programme de soins prévu par la loi du 5 juillet 2011

ObjectivesThe law of 5 July 2011 introduced the possibility of outpatient care without consent in the context of care programs (CP). Despite major ethical and legal issues and frequent recourse in France, few studies are available on the use of this mechanism. An in-depth review of practices involving a large sample of CP was essential. The main objective of this study was to look at their content, the clinical profile of the patients involved, and the progress of these CP.MethodsWe carried out a retrospective, observational study, including all the CP set up between January 1st, 2016 and December 31st, 2018 in the Sarthe department. Data strictly related to the CP (content, justification, duration, patient compliance, re-hospitalizations, etc.), and patient-related variables (socio-demographic characteristics, diagnosis, antecedents, etc.) were studied.ResultsWe studied 559 CP, 70 % of which (n = 391) in the context of “care by decision of the hospital director”, with a wide disparity of recourse by psychiatric sector. One third of the hospitalizations without consent ended with a CP. They involved men (68.5 %, n = 383), with a psychotic disorder (77.8 %, n = 435), with a history of hospitalization (90 %, n = 503), and with poor adherence to care (83.2 %, n = 465). Cannabis use accounted for 41.3 % (n = 231) of cases. Certificates initiating CP did not have a clear justification (34.6 %, n = 251) or state a goal of adherence to treatment (16.5 %, n = 120). The content of the different CP was homogeneous: 65.6% of medical consultations and 47.6 % with a nurse, 100 % mentioned treatment used. Their average duration was 3.4 months. Even though the CP were followed (69.9 %, n = 391), 52.8% (n = 295) ended with reintegration, mainly justified by symptomatic relapse (34.8 %, n = 147), and new CP were put in place almost systematically (90.6 %, n = 260). However, reintegrations were shorter than first-time admissions (26 vs. 95 days). When a decision was lifted (n = 174), it was based on the criteria of clinical stability (35.7 %, n = 120) and compliance with the CP (27.6 %, n = 93). Half of hospitalizations in “care at the decision of the State representative” ended with a CP. These CP were longer (4.5 months) and with a higher rate of reintegration (62.2 %) than for those in “care at the decision of the hospital director”. There was no significant difference of CP compliance according to the mode of psychiatric care.ConclusionsOur study allows a precise vision of patients concerned by CP: men with risk factors for psychiatric dangerousness, with a severe clinical profile. It also found a high rate of re-hospitalization despite good adherence with the CP which is in line with a device allowing the work of an alliance to care and interventions at the beginning of relapse. CP have poorly personalized content and are poorly justified by psychiatrists although it is a freedom-restricting measure, highlighting the need for increased awareness amongst psychiatrists of the legal framework of their practice regarding care without consent.     

The influence of caregiver attitudes and socioeconomic group on formal and informal mental health service use among youth

BackgroundYoung people can receive mental health care from many sources, from formal and informal sectors. Caregiver characteristics/experiences/beliefs may influence whether young people get help and the type of care or support used by their child. We investigate facilitators/barriers to receiving formal and/or informal care, particularly those related to the caregiver’s profile.MethodsWe interviewed 1,400 Brazilian primary caregivers of young people (aged 10–19), participants of a high-risk cohort. Caregivers reported on young people’s formal/informal mental health care utilization, and associated barriers and facilitators to care. Data were also collected on youth mental health and its impact on everyday life; and caregiver characteristics—education, socioeconomics, ethnicity, mental health, and stigma. Logistic regression models were used to examine the relationship between caregiver and young people characteristics with formal/informal care utilization.ResultsPersistence and greater impact of youth mental health conditions were associated with a higher likelihood of care, more clearly for formal care. Caregiver characteristics, however, also played a key role in whether young people received any care: lower parental stigma was associated with greater formal service use, and lower socioeconomic class showed higher odds of informal care (mainly from religious leaders).ConclusionsThis study highlights the key role of the caregivers as gatekeepers to child treatment access, particularly parental stigma influencing whether young people received any mental health care, even in a low resource setting. These results help to map barriers for treatment access and delivery for young people, aiming to improve intervention efforts and mental health support.     

Neutrophil-to-Lymphocyte Ratio and Response to Intravenous Thrombolysis in Patients with Acute Ischemic Stroke

Background and Aims: The Neutrophil-to-Lymphocyte Ratio (NLR) is suggested as a readily available and inexpensive biomarker to predict prognosis of acute stroke. Experience with intravenous (IV) tissue plasminogen activator (tPA) treatment is limited. Methods: Total 142 (80 female, age: 69 ± 13 yearr) consecutive acute stroke patients treated with IV tPA were evaluated. Admission and 24th hour lymphocyte, neutrophil, and monocyte counts were measured and the NLR was calculated. Results: Average NLR elevated (by 3.47 ± 6.75) significantly from admission to 24th hour (P< .001). Total 52% of patients exerted good response to IV tPA (NIHSS ≤1 or decrease in NIHSS ≥4 at end of 24 hour), while 27% showed dramatic response (decrease in NIHSS ≥8 at end of 24 hour). The patients with “thrombolysis resistance” had significantly higher 24 hour Neutrophil-to-Lymphocyte Ratio (24h NLR) (P= .001). At the end of 3rd month, 46.5% of patients had favorable (modified Rankin's score, mRS 0-2) and 32.4% had excellent (mRS 0-1) outcome. Patients without favorable/excellent outcome had significantly higher 24h NLRs. Regression analysis indicated that post-tPA, but not admission NLR, was an independent negative predictor of excellent (β =?.216, P= .006) and favorable (β = ?.179, P= .034) outcome after adjustment for age, hypertension, and admission NIHSS. Nine patients who developed symptomatic intracerebral hemorrhage had elevated pre-tPA (7.6 ± 7.39 versus 3.33 ± 3.07, P< .001) and 24h NLR (26.2 ± 18.6 versus 5.78 ± 4.47, P< .001). Of note, receiver operating characteristics analysis failed to detect any reliable NLR threshold for absence of tPA effectiveness/dramatic response, 3rd month good/excellent outcome or any type tPA-induced hemorrhage. Conclusions: As a marker of stroke-associated acute stress response, the NLR, which increases during the first 24 hours, is an epiphenomenon of poor prognosis. However, pretreatment NLR values have no importance in predicting IV tPA response.     

The Fragility Index in Randomized Controlled Trials for Patent Foramen Ovale Closure in Cryptogenic Stroke

Background and Purpose: The routine use of percutaneous transcatheter patent foramen ovale closure (PPFOC) to prevent recurrent stroke in patients with cryptogenic stroke is still a matter of debate after completion major randomized controlled trials (RCTs). Methods: The fragility index of RCTs evaluating effect of PPFOC against medial therapy alone in stroke prevention was calculated to assess the robustness of statistically significant findings. Results: Literature search with PubMed identifies 6 RCTs on PPFOC. Median number of patients who underwent PPFOC and medical treatment were 340 and 229, respectively. Median number of the patients lost to follow-up was 20 in PPFOC and 18 in medical group. Fragility index was 0 for 4 studies. Median fragility index was also 0 for both “stroke” (interquartile range: 0-5.3) and “combined stroke and TIA” (interquartile range: 0-2) endpoints. In all studies except CLOSE, fragility index was smaller than or equal to the number of the subjects lost to follow-up. Conclusions: Recent positive results of PFO closure studies should be interpreted cautiously because of their fragile characteristics. Routine PFO closure should be reserved for prevention of recurrence when suspicion for paradoxical embolism is high. Detailed individualized decision-making is crucial before ordering PPFOC for stroke prevention in patients with cryptogenic embolism.     

Even Faster Door-to-Alteplase Times and Associated Outcomes in Acute Ischemic Stroke

Background and Purpose: The timely administration of thrombolytic therapy for acute ischemic stroke has been associated with good functional outcomes. Current guidelines recommend alteplase administration within 60 minutes in 75% of eligible patients and within 45 minutes in 50% of patients. There is limited evidence guiding these measures and their effect on outcomes. We report a single-center, retrospective assessment of the safety and efficacy of alteplase treatment within 45 minutes. Methods: Five hundred and eighty-six patients were treated with alteplase in our emergency departments (EDs) between January 2014 and October 2016; 368 patients were included for analysis. Multivariate regression analysis was used to assess the association between door-to-alteplase (DTA) times and 90-day modified Rankin scale (mRS) scores. Incidence of intracerebral hemorrhage (ICH) was also documented. Results: The median DTA time was 29 minutes versus 64 minutes in the DTA less than or equal to 45 minutes arm and more than 45 minutes arm, respectively. The primary outcome of 90-day mRS 0-1 was achieved in 56% of patients in the less than or equal to 45 minutes group versus 58% in more than 45 minutes group (P = .67). Odds of achieving mRS 0-1 were not significantly impacted by DTA times. In the multivariate regression analysis, patient characteristics associated with achieving mRS 0-1 were: younger age, male sex, not requiring intubation in the ED, and without prior history of hypertension, atrial fibrillation, or stroke. There was no significant difference in rates of ICH for patients less than or equal to 45 minutes versus more than 45 minutes. Conclusions: Rapid administration of alteplase was not associated with significantly better outcomes nor increased risk of ICH. Conclusions about efficacy are limited due to the retrospective nature of the study, small sample size, and incomplete data points.     

Children at Risk: Outcome and Cost Measures Needed

Sporadic reports in the media focus on the difficulty of America's social welfare leadership to protect children at risk and to allocate scarce resources. These criticisms suggest the need for valid conclusions in both socio-psychological and economic terms for evaluating the efficacy of three key strategies used for children at risk: reunification, foster and kinship care, and adoption. This article calls for creating a comprehensive data base that supplies the most critical variables leading to reasonable successes and the average cost per case when comparing children reunified with a biological parent to those who are placed into out-of-home settings and to those who are adopted. This analysis to include public and private expenditures for services provided by human services-welfare, special education, judicial, correctional, mental health, medical, and other related organizations.     

The relationship between general and specific attribution of blame for a "serious" act and the role of personality

Methods for regular monitoring of care and services are needed for psychiatrists to act on, to refine practice. We developed a computer-based instrument to be used by staff working with schizophrenic patients. The instrument was tested in a group of patients randomly assigned to an integrated-care program. Data on time, place, direct/indirect contacts, and the main elements of the content of care were regularly recorded on a pocket computer and later transferred to a desktop computer for analysis. One-year data on 24 subjects are presented on three levels: individual, case load, and total patient population. Of the encounters 66% were individual patient contacts. Staff spent 59% of the time at patients' homes. A computer-aided system with built-in information on care delivery, program fidelity, and outcome can be the basis of decision-making on different health-management levels.