Guía para el manejo de las crisis epilépticas en cuidados paliativos: propuesta de un modelo actualizado de práctica clínica basado en una revisión sistemática de la literatura

Introduction

Very little has been written on seizure management in palliative care (PC). Given this situation, and considering the forthcoming setting up of the Palliative Care Unit at our neurorehabilitation centre, the Clínica San Vicente, we decided to establish a series of guidelines on the use of antiepileptic drugs (AEDs) for handling seizures in PC.

Estudio del efecto del tratamiento con inmunoglobulinas por vía intravenosa en la neuromielitis óptica

Objective

Evaluate safety and tolerance levels for intravenous immunoglobulins (IVIG) as treatment for neuromyelitis optica (NMO).

Methods

Eight patients meeting Wingerchuk's revised diagnostic criteria were treated with IVIG every 2 months (0.7 g per kg body weight per day for 3 days). The primary outcome measure was the occurrence of serious adverse effects, defined according to NIH guidelines for clinical trials. Secondary outcome measures were changes in the yearly rate of attacks and in the degree of neurological disability measured with the Expanded Disability Status Scale (EDSS).

Results

All 8 patients were treated; 5 had relapsing optic neuritis with or without myelitis and 3 had recurrent longitudinally extensive transverse myelitis. The mean age of onset was 20.5 years (range, 7-31 years) and 87,5% were female. The mean duration of the disease before beginning treatment was 9.0 years (range, 3-17 years). Following 83 infusions (range, 4-21 per patient) and a mean follow-up time of 19.3 months (range, 6-39 months), minor adverse events had occurred (headache in 3 patients and a mild cutaneous eruption in a single patient). The relapse rate decreased from 1.8 in the previous year to 0.006 during follow-up (z= 2,5, P=.01). The EDSS score fell from 3.3 ± 1.3 to 2.6 ± 1.5 (z = −2.0, P=.04).

Conclusions

Treatment with IVIG is safe and well-tolerated, and it may be used as a treatment alternative for NMO spectrum disorders.     

Importancia del tamaño de las tuberosidades en las complicaciones del complejo esclerosis tuberosa

Introduction

Tuberous sclerosis complex (TSC) is one of the most frequent neurocutaneous disorders. Cortical tubers are the most common pathological changes in TSC and they are directly related to the disease's main clinical manifestations: seizures, mental retardation, and autistic behaviour.

Objective

The aim of this study is to establish a correlation between tuber size and the severity of clinical features in TSC.

Material and methods

We performed a retrospective study of the clinical and imaging findings from 45 TSC patients (22 females and 23 males) and compared the clinical features with the location, size, and number of the cortical tubers in each patient.

Results

Four patients had voluminous tubers located in 1 or both cerebral hemispheres. All of these patients had intractable seizures and severe mental retardation; 3 of these cases also presented with autistic behaviour, despite tubers having been resected in all 4 patients. Thirteen patients had tubers of large-to-average size, and all patients in this group showed intractable seizures and mental retardation. Nine patients who had experienced infantile spasms during the first year of life presented autistic behaviour. Multiple tubers of small to average size were found in 28 patients. In general, this group had seizures that responded well to antiepileptic drugs and a low prevalence of autism. In 3 patients who all presented good seizure control and normal intelligence, single cortical/subcortical tubers were located in the frontal or occipital lobes. Of the total of 45 patients, 13 had cerebellar as well as cerebral tubers; these were generally present in cases with more severe clinical features.

Conclusions

Although large tubers are less common than small to medium-sized ones, they are much more likely to be accompanied by severe clinical symptoms (seizures, mental retardation and autistic behaviour), even when the smaller tubers are quite numerous.     

Folies de voisinage, folie à deux ? Étude de cas

The case of two neighbors living next to one another who were successively hospitalized for a mentally delirious condition with several similar aspects has raised the question of whether, apart from the state of neighborhood dementia, there might not exist another form, that is to say, psychosis due to close association. A review of clinical case histories demonstrates that psychosis due to close association is not a single state, but is divided into several distinct forms, notably the following: apart from the classical form of neighborhood dementia, a mentally contagious condition, the other forms include communicated dementia and simultaneous dementia, with examples of clinical case histories which have been presented for the latter category.     

Recherche de sensations, désinhibition et pratique de sports à risque : quelques pistes de réflexion

Sensation seeking is at the root of different behaviours. Skydivers, artists, drug addicts and criminals somehow share the same need for stimulation. But are there drug-addicted skydivers? Are there different ways to seek sensations? Studies on risky sport practices and disinhibition are contradictory. While some find risk-taking athletes do not consume substances, others maintain these athletes are indeed the most uninhibited of all. Diversity and the type of activities supposedly depend on what exactly an athlete seeks from a psychological point of view. The analysis of different sensation seekers’ personality traits helps to better understand the choice and role of one or several sources of activation. Based on a review of studies, we will discuss three sensation seeker profiles. Depressed “escapists” primarily seek sensations through substance use in order to regulate their negative affects. This “passive” stimulation mode seems better suited than practising risky sports for these individuals lacking in energy. Conversely, extraverted “hedonists” comfort their positive affectivity by seeking multi-faceted pleasure in risky sports or the “social” use of substances. They are not characterized by negative affects but by alexithymia. Some probably bypass their difficulty to understand their feelings by seeking various readily available sensations that need not be mentally interiorised (purportedly found in disinhibition or risky sports). Finally, “compensatory” types are adventurers who seek sensations in high-risk sports only. They are not characterized by depression, anxiety, disinhibition, extraversion or alexithymia. They seek to enhance and build up their personality by confronting the natural environment and danger. While all athletes seek sensations, these might not be essential to escapist and compensatory types who use them only as a mere means to escape and compensate. Extraverted hedonists seem to be the “true” sensation seekers inasmuch as stimulations are worthwhile in themselves. This strong need for hedonistic sensations might lead to an addictive process, a common answer to psychic sufferings that may also derive from boredom or a need for sensations and pleasure.     

Innocence,déni,aveu, culpabilité : conclusion de la journée

The author reviews the various papers presented during this meeting. He concludes that forensic psychiatric assessment has to become more scientific and forensic psychiatry must be necessarily taught to judges and psychiatrists.     

Étude de la dépression,des événements de vie,de l’impulsivité et du lieu de contrôle au sein d’une population nouvellement incarcérée

Introduction

During the first days of incarceration, the “shock prison” may encourage the appearance of symptomatology reaction with the presence of depressive disorders. Several studies in prisons showed the presence of certain socio-demographic characteristics, psychological and legal in this population life course singular susceptible to weaken against the event that represents an incarceration.

Objective

The present study is twofold. This is firstly to assess depression, life events, impulsivity and locus of control in a newly incarcerated population and secondly to compare the results with depressed people those do not show depression.

Method

Maintenance of semi-structured research was proposed to 46 inmates in the unit of outpatient consultations in a prison in 2010. This interview was completed by placing two questionnaires (Beck Depression Questionnaire, Eysenck Impulsivity Questionnaire) and scale (Multidimensional locus of control scale of Levenson).

Results

Of the forty four inmates incarcerated for less than 10 days, who participated in the study twenty-six had a depression, a significant number of incarceration, psychiatric history, certain life events (personal and maternal abuse, parental alcoholism), as well as significantly higher scores with regard to empathy and external locus of control type “powerful character”.

Conclusion

Home maintenance is a systematic critical time. Newly incarcerated population, with a depression score above the standard psychological characteristics show support from the idea of a unique formation of the personality associated with the presence of life events and highlights particularly difficult childhood susceptible to weaken, especially to cope with the event that is incarceration.     

Processus psychopathologique, sentiment et syndrome de vulnérabilité

The aim of this paper is to show the interest of taking into account, in the psychological reflection, the feeling of vulnerability met by a patient at the beginning of the psychopathological process. The authors attempt to specify the diverse modalities of the vulnerability, the nature of the predisposition and of its factors, the differences between the deeply lived feeling and the syndrome, revealed into the identitary weakening itself. They examine the way from the feeling to the syndrome of vulnerability, being like a terrifying waiting of a internal disintegration, from extreme situations, intentional or imposed. The clinical approach of psychical weakness of the elderly people and of the inaugural experiences of the schizophrenia (particularly the case of Suzanne Urban), permits to precise the processual nature of the syndrome of vulnerability. It proposes a new reading of some syndromes of acute psychic disorganization.     

Insight, dépression, estime de soi et satisfaction de vie chez des personnes souffrant de schizophrénie

Recent studies on insight in schizophrenia, mainly english-speaking, have shown that denial of mental disorder (lack of insight) is connected with a less good compliancy with treatment. Consequently, therapies, which increase insight, develop currently (psychoeducation and information of patients, for instance). Nonetheless, certain studies concluded that awareness of mental disorder has a negative effect on psychological dimensions like humor, self-esteem and quality of life. So we realize a pilot-study on 20 schizophrenic subjects (DSM-IV) (15 men and five women including 13 full-time inpatients and 7 days in-patients) from 22 to 61 years (m = 41.75; σ = 11.94). The aim of the study was to measure insight (IS and Q8), depressive experience (SCL90-R and CDSS), self-esteem (SEI) and satisfaction with life (SWLS), then to calculate correlation between insight and the three other dimensions. Data analysis confirmed a strong link between insight and deterioration of self-esteem (r = −0.6922; p = 0.001) and with an increase of depressive experience (r = 0.8134; p = 0.000 with SCL90-R and r = 0.6041; p = 0.006 with CDSS). Satisfaction with life is not significantly correlated with insight (r = −0.2047; p = 0.401). Those results show that clinicians must take into account the depressive effect of therapeutic strategies aiming at an increase in insight.     

Fréquences de la consommation de substances psychoactives et de la psychopathologie chez de jeunes adultes en première année d’Université

Understanding the etiology of alcoholism and drug addiction requires knowledge of the frequency of substance use in young cohorts, as well as the role of specific vulnerabilities that may explain the later development of these disorders. In the public health domain, efficient programs of prevention depend on the understanding of substance use in general population. The present study examined these issues in a large sample of university students, with particular attention to the risk factor of comorbid psychopathology.A two-phase sampling plan was used with post-stratification on substances use. In the first stage, an initial sample of 1 517 students was pre-selected based on responses to a battery of self-questionnaires, including information concerning recent consumption of substances (alcohol, cannabis, cocaine, heroin, acid, solvents…). 224 subjects were then selected in the second phase to compose four groups of substance users: infrequent consumers (those who did not use any substance during the last month; N = 80); frequent consumers of alcohol only (with a consumption of alcohol of several times a week to several times a day, regardless of tobacco use but with no other substance use; N = 44), frequent consumers of cannabis (consumption of cannabis of several times a week to several times a day, regardless of tobacco and alcohol use but with no other substance use; N = 54) and consumers of other illicit substances (consumption of hallucinogens, cocaine, heroin, ecstasy, or other illicit substance at least once during the last month; N = 46). These representative subgroups of infrequent and frequent users were then administered a psychiatric diagnostic interview (Mini International Neuropsychiatric Interview; MINI, version 5.0) to assess affective and mood disorders and substance use disorders. At the end of the study, all participants received 75 € ($100).The findings indicate maintenance of trends observed in France since 2000 for the stabilisation of alcohol use, a decrease in tobacco use, and an increase in cannabis among this age cohort. Nevertheless, it’s important to note that these frequencies are based on frequent use of substances and, even if most of users do not fulfil criteria for abuse or dependence, such levels of consumption may have serious consequences for daily functioning and physical or mental health. In examining this issue, the percentage of comorbid psychopathology was found to be generally higher in substance using groups than in the control group, but these differences were significant only for consumers of illicit drugs. The findings are discussed in terms of consequences for the overall psychosocial functioning of young substance users and relative to the increased risk of developing a substance use disorder.     

Traitement pharmacologique de l’état de mal réfractaire

Status epilepticus (SE) refractory to benzodiazepines and other antiepileptic agents is managed with intravenous anesthetic compounds, such as thiopental, propofol or midazolam. These drugs display quite different pharmacodynamic and pharmacokinetic properties, but have not been prospectively compared to date. Their use is clearly advocated for the treatment of generalized convulsive SE, whereas partial-complex, or absence SE are generally managed less aggressively, in consideration of their better prognosis. The most important aspect seems to be related to the correct use of these anesthetics in the right context, rather than the choice of one specific compound. An electroencephalographic burst-suppression should be targeted for about 24 hour, before progressive weaning of the dosage under EEG monitoring. If this approach proves unsuccessful, the use of other drugs, including inhalational anesthetics, has been described.     

Secteurs psychiatriques et circuits de l'information en matière de précarité

The public service for mental health has been facing a conjuncture with necessary modifications to be made. In this context, we felt that it would be appropriate to carry out a survey in 2000, and then in 2002, on how much psychiatric districts know and are informed about access to general medical care and rehabilitation. Psychiatric staff seemed indeed to pay particular attention to those who may benefit from existing social systems and not only in connection to new legislations. According to our estimates, 19 % of patients under psychiatric care benefit from the Universal Medical Coverage (Couverture Médicale Universelle, CMU). The CMU was considered to be a good measure for patients by most medical and social partners polled. The latter emphasised the relevance of covering hospital fees and making access to general medical and dental care, which is otherwise often disregarded, easier. Moreover, districts themselves suffer from institutional “precariousness”. Tensions occur in the first place when, despite their willingness to deal with issues or problems, they are unable to do so.