血栓弹力图评价缺血性脑血管病患者服用不同小剂量阿司匹林疗效

抗血小板药物能显著降低非心源性脑缺血性卒中或TIA患者再次严重血管事件的发生率[1].阿司匹林和氯吡格雷是经循证医学证实可常规应用的抗血小板聚集药,2010年中国缺血性卒中或TIA发作二级防治指南及2011年AHA/ASA关于缺血性卒中或TIA发作患者卒中预防指南指出:对于非心源性缺血性卒中和TIA的抗栓治疗,氯吡格雷75mg和阿司匹林50mg～325mg均可作为首选药物[2,3].     

阿司匹林抵抗与基因多态性关系研究进展

正最新死亡原因分析报告~([1])显示,在全球大多数地区,缺血性心脏病和脑梗死是导致死亡的主要原因。研究表明~([2]),阿司匹林能够有效降低缺血性卒中患者的死亡率及非致死性复发性卒中的发生率。然而,临床上仍有部分患者在长期服用治疗剂量阿司匹林期间发生严重的缺血性卒中事件,这是因为血小板对阿司匹林的反应性并非在所有个体中都相等,阿司匹林抵抗(AR)的发生率存在很大差异(0.4～83%)~([3])。Gum和他的同事们指出,约10%的复发性血管事件可归因于AR~([4])。本文将从阿司匹林代谢基因多态性的角度阐述在抗血小板治疗与预防过程中发生AR的可能原因,进一步指导高危缺血性疾病患者的个体化治疗。     

急性缺血性卒中的抗血小板治疗

急性缺血性卒中患者血小板被激活，抗血小板治疗可减少早期脑梗死的复发，减轻脑损伤的体积，降低早期死亡和改善存活者的长期预后。但抗血小板治疗增加非致死性或症状性颅内出血的发生率。阿司匹林是证据最充分且得到各国指南推荐的治疗急性缺血性卒中的抗血小板药物，对未溶栓治疗的急性缺血性卒中患者应尽早开始阿司匹林治疗。氯吡格雷、血小板糖蛋白Ⅱb/IIIa受体抑制剂、双嘧达莫、西洛他唑等单药用于治疗急性缺血性卒中的安全性和疗效目前尚无足够的证据。抗血小板药物联合应用的疗效和可能的风险尚需进一步研究。     

非心源性缺血性卒中及短暂性脑缺血发作患者的抗血小板治疗

在脑血管病患者中,约80%为缺血性卒中患者,多伴有多种危险因素,是卒中复发的高危人群。在非心源性缺血性卒中/短暂性脑缺血发作（transient ischemic attack,TIA）的二级预防中,抗血小板治疗的疗效已被大量临床研究证实,并被各国的指南所推荐。本文结合新近发表的指南以及经典的临床试验,对非心源性缺血性卒中/TIA的抗血小板治疗模式做一综述。     

《中国卒中杂志》关于征集“缺血性卒中/TIA抗血小板治疗临床研究基金”方案的通知

<正>为了促进创新型青年人才的成长,支持中国神经内科临床医师的研究工作,规范"缺血性卒中/TIA"抗血小板药物的规范化应用,探索抗血小板治疗临床研究的新方向,由深圳信立泰药业股份有限公司支持,《中国卒中杂志》社设立"缺血性卒中/TIA抗血小板治疗临     

缺血性卒中的双重抗血小板治疗

正脑梗死发病初期是病情复发的高危时期。研究表明,发病30d后卒中的复发率为1.1%~15%[1],TIA的复发率更高达17%[2]。因此,缺血性卒中患者早期启动抗血小板药物治疗对预防卒中的复发至关重要。其中,联合应用抗血小板药物治疗通过阻断血小板不同的激活途径更有效的阻止血小板活化作用。2002年阿司匹林和氯吡格雷的联合应用成为急性冠脉综合征及接受经皮冠状动脉介入的指南推荐疗     

抗血小板药物抵抗与复发性缺血性脑卒中

缺血性脑卒中在抗血小板治疗期间1/3~1/2的患者卒中复发。卒中复发有多种原因,多认为病人的不依从性是实验室抗血小板药物抵抗的最常见原因,但需要正确识别卒中的原因和发病机制。目前还没有良好指征用于缺血性卒中抗血小板药物抵抗的检测,或根据检测结果调整药物剂量的方法。选择预防卒中复发的抗血小板药物取决于卒中发作的时间,轻度缺血性卒中在发病3个月内选用阿司匹林联合氯吡格雷优于单一的抗血小板药物,但对长期二级预防来说,联合应用抗血小板治疗不仅无益处,且有增加出血的风险。     

《中国卒中杂志》关于征集“缺血性卒中/TIA抗血小板治疗临床研究基金”方案的通知

<正>为了促进创新型青年人才的成长,支持中国神经内科临床医师的研究工作,规范"缺血性卒中/TIA"抗血小板药物的规范化应用,探索抗血小板治疗临床研究的新方向,由深圳信立泰药业股份有限公司支持,《中国卒中杂志》社设立"缺血性卒中/TIA抗血小板治疗临床研究基金"项目。现将有关事项通知如下:     

脑白质疏松和陈旧性腔隙性脑梗死对首发缺血性卒中患者预后的影响

目的 探讨脑白质疏松和陈旧性腔隙性脑梗死对于首发缺血性卒中患者预后的影响。 方法 连续选取791例7 d以内首次发病的非心源性缺血性卒中患者。收集患者的人口学信息和脑血 管病的危险因素,评价患者的头颅磁共振成像包括脑白质疏松的严重程度、无症状性腔隙性脑梗死 的数量、缺血性卒中的病因分型以及急性梗死灶的分布特征,通过多因素Logistic回归分析脑白质疏 松和陈旧性腔隙性脑梗死与缺血性卒中患者预后相关的危险因素。 结果 分别有14例（1.8%）、38例（4.8%）患者在缺血性卒中发病1年内死亡、缺血性卒中或短暂性脑 缺血发作（transient ischemic attack,TIA）复发。多元Logistic回归发现：存在陈旧性腔隙性脑梗死、有 皮层新发脑梗死灶、入院后未给予抗血小板药物、出院时未服用他汀药物是缺血性卒中患者1年内 死亡的危险因素;而脑白质疏松对于缺血性卒中患者1年内的死亡无显著影响。冠状动脉粥样硬化性 心脏病、入院美国国立卫生研究院卒中量表（National Institute of Health stroke scale,NIHSS）评分<4 分、新发梗死灶的责任脑动脉闭塞或狭窄程度≥70%、出院时未给予抗血小板药物是缺血性卒中患 者1年内缺血性卒中或TIA复发的危险因素;而脑白质疏松和陈旧性腔隙性脑梗死对于缺血性卒中患 者1年内缺血性卒中或TIA的复发无显著影响。 结论 陈旧性腔隙性脑梗死是缺血性卒中患者1年内死亡的危险因素。而脑白质疏松和陈旧性腔隙 性脑梗死对于缺血性卒中患者1年内缺血性卒中或TIA的复发无显著影响。     

抗血小板治疗在血管内治疗缺血性脑血管病中的应用

血管内治疗能显著降低缺血性脑血管病的致残、病死及卒中复发率。随着神经介入技术 和材料以及患者筛选策略的进步，缺血性卒中患者应用血管内治疗也日益增加。抗血小板治疗作为 缺血性卒中预防和治疗的重要手段，是血管内治疗中的重要一环，阿司匹林、氯吡格雷等是基石性 抗血小板药物，但具体的用药方案尚不统一。本文回顾和总结了国内外指南针对缺血性脑血管病行 血管内治疗患者的抗血小板策略建议，以及重要血管内治疗研究中采用的抗血小板治疗方案，以期 为神经介入医师行血管内治疗时抗血小板药物的应用提供参考。     

L' « Ouverture émotionnelle » dans les Troubles de la dépendance et les Troubles de la personnalité

Emotion processing is supposed to play an important role in psychological dysfunctions in alcohol and drug dependency disorders (DD), as well as in personality disorders (PD). The model of “Emotional Openness” (“Ouverture émotionnelle”) provides a multidimensional framework to analyze problematic patterns of emotion processing. Within this framework, it is suggested that drug- and alcohol-dependent patients as well as borderline and antisocial patients show reduced a) “cognitive/conceptual representation” of affective states; b) “emotion regulation”; and c) “expression and communication of emotion”; but d) increased “awareness of body internal indicators” of affectivity; and e) appropriate psychological treatment is supposed to improve these patterns. Drug-dependent patients with PD comorbidity (in particular borderline or antisocial) are supposed to present even stronger deficits in (a) and (b). The hypotheses are tested with the 36-item DOE questionnaire (“Dimensions of Openness to Emotional experiences”, trait version; [19]), assessing six main dimensions of emotion processing as represented by the subject (French and Italian version). The instrument presents satisfying reliability coefficients (mean alphas of the scales in two recent studies (N = 251; N = 435) vary between 0.74 and 0.82) and good factorial validity (6-factor PCA solutions with varimax rotation solutions in the two samples are highly coherent; the mean of Tucker's congruence coefficients is 0.93). Results of two clinical studies are presented, comparing N = 71 patients (21 drug-dependent without personality disorder; 30 drug-dependent with borderline or antisocial personality; 20 dependent in-patients receiving psychological therapy) with normal control subjects (N = 51 matched; N = 50 reference group), including one pre-post treatment comparison. Results confirm marked deficits of DD patients concerning “conceptual representation” and “emotion regulation”, as well as a reduction of “communication/expression of emotion” but an increased “awareness of body internal indicators” of affectivity. Differences of patients with a double diagnosis correspond to effect sizes of d = -1.33 for cognitive/conceptual representation of emotions and d = -1.25 for emotion regulation; differences in emotion communication and expression are also significant but less important d = -0.44. Awareness of body internal emotion indicators is increased (d = +0.27) but does not differ significantly from the control group. As supposed, patients with a double diagnosis (DD and PD) described significantly stronger deficits in conceptual representation and emotion regulation than the patients with dependency disorder only. In the second study, a group of DD patients receiving multi-component treatment, including individual and group therapeutic intervention, according to the client-centered approach, and working on emotion processing, showed marked differences from the reference group at the beginning of the treatment (d = -0.91 for cognitive/conceptual representation, d = -0.82 for emotion regulation and d = +0.46 for awareness of bodily internal indicators). As supposed, pre-post comparisons indicate improvement with change effect sizes of d = 0.99 for conceptual representation, d = 0.97 for emotion regulation, as well as d = 0.88 for emotion communication and expression. Furthermore, the changes following treatment are highly significant and substantial, except for the awareness of internal bodily indicators, which only slightly decreased. Patients “normalize” their emotion processing following treatment, describing increased conceptual representation and emotion regulation, as well as emotion communication and expression. Results underline the importance of dysfunctional modes of emotion processing in both pathologies, and underline the validity of applying the model and the DOE instrument. They are discussed with reference to the model of alexithymia.     

Une phénoménologie de la dépendance à l'alcool. Une expérience primordiale de la « nostrité »

The phenomenological approach to alcoholism interestingly focuses on specific dynamics of interpersonal relationships displaying the founding of the Self from a primary “us” and its original basis in the human feast. Priorities for treatment intervention recommend to involve social setting and relationships of the patients, reaching their active participation to a motivational and long term group treatment, underlying the specific therapeutic effect of world exchanges. Biopsychosocial determination of alcoholism could be primarily based on components of interpersonal relationships. Regarding social background, drinking is one of the most famous supports for the achievement of the feast, a founding marker of present time. Taking an existential point of view, the feast appears as the heart of mankind because it presents a primary “us”, a plural state which indicates the beginning and founding of the Self from the others. During the feast, we regularly have to reach our Self from the “us” while avoiding two main dangers, drunkenness, an increase in the dizziness of upright verticality, and addiction, an opposite vertical surrender to alcohol and falling into in the alcoholic relapse, both situations imply a spatial domination and the disappearance of others. Treatment programs of alcohol addicts need to integrate the necessity of reaching the existential basic trust from the support of a group to the appropriation of the community which can be defined as an original “usness”.     

Expertises pour la sécurité sociale : méthodologie et spécificités

Mental disorders represent in France for the Social Security the second post of spending in consumption of care with 11,4 billion euro, that is 10,6% of the spending, behind the diseases of the circulatory system. They stay in the rank of the pathologies justifying the allocation of a disability pension, representing 26,7% of invalids. It is to say the importance of the psychiatric expertise for the Social Security. This type of expertises is particular among the expertises in psychiatry because the objective of the expertise is to establish an arbitrage between the position of CPAM's doctor and his regular doctor. Effectively, except legal flaw, the opinion of the expert imposes upon the parts (parties). The realization of the expertise and its editorial staff are detailed in their specificities. Problem specific of the psychiatry are approached as well as the functions (offices) of the expert which are well beyond arbitrator's role towards a function of teacher and intermediary.     

Rôle des équipes de soins dans l'évaluation et la prévention de l'agressivité

Aggressiveness and violence in psychiatric wards have been common for some time. Situations that incur risks may originate at different levels such as the feeling that one is not heard, a break with one's entourage, feelings of isolation, factors related to pathology, postponing a treatment, the prohibition of smoking in the rooms... Further to the analysis of the relative situation of the patient, it is of utmost importance that the team pay attention to it's own sentiments of fear, to its divisions, to its feelings of distress and of its difficulties with some patients. On the other hand, conversations, follow-up at patient's homes and out of hospital psycho-educative groups are set up to allow patients to better manage their treatment, to detect risk situations for themselves and to detect early signs of relapse so as to forestall crisis situations and to avoid re-hospitalisation.     

Travail psychanalytique, transfert et maniement du transfert dans la cure des personnes diagnostiquées « psychose » ou « schizophrénie »

The possibility of a psychoanalytic treatment or cure in the case of a psychotic patient is the controversial subject of many discussions. We are reminding in this paper Freud's different positions about this subject, in order to show his ambivalence. We examine further the hypotheses and techniques that are proposed by several schools of psychoanalysis and we show how the technical rules of the treatment are resulting mainly of theses hypotheses concerning the etiology and the pathology. The technical rules are inducing a particular position of the analyst, which is different for each school. We assume that these postures are not excluding each other, but they are reflecting particular “moments” of the treatment, or specific “techniques” which are more or less appropriated for each category, we explicit different postures and we match they with these proposed by Freudian, Lacanian or Kleinian authors. The imaginary transference is the one described by Freud in “An Outline of Psychoanalysis”. It represents the transfer on the analyst's person of an early significant figure (imago). We argue the idea that the initial transference of a psychotic person is a transfer of “functions”, as in the R-scheme described by Lacan. The symbolic transference involves the language, i.e. the working out of a delusion. The real transference is the contrary of the neurotic process of “uncovering” the object: it is the one, which grasp the object into the discourse. We argue the idea that there is a possibility of structural mutations between psychosis and neurosis. The structure is conceived as a preferential pattern of relationship (transference) at a “m” moment.