À propos du post-partum blues

Since postpartum blues was described by Savage in 1875, the controversy regarding its nature and cause has been sustained. In a first part, the author reviews the conventional clinical assessment of the blues as described in international medical literature. Its constitutive symptoms are mundane, of an affective, emotional, cognitive or psychosomatic nature. On the other hand, their originality resides in the mildness, unusual nature and progressive profile of their expression. Some elements speak in favour of the normality of this phenomenon, such as its mildness and great frequency. But others give indication of a pathological process, notably its links with various entities or illnesses such as the premenstrual syndrome, acute psychoses and postpartum depressive moods. This aspect has moreover led to search for shared causes to these different co-morbidities, such as a constitutional predisposition, somatobiological disorders, a psychosocial condition or psychodynamic mechanisms. This debate, however, is far from being settled. In a second part - and in continuity with a previous work - the author adds three other symptoms to this classical approach: drop in intrinsic weight, decrease of activity and positivity to the dexamethasone test. In order to do so, he defines the notion of “gross prepartal weight” (weight as measured before delivery) and “neat prepartal weight” (resulting from the substraction of the foeto-annexial package from the gross prepartal weight). At the same time, he compares these data with those resulting from a questioning of twenty-one new mothers out of a university hospital ward on obstetrical difficulties, end-of-pregnancy psychic disorders or PMS case history. These analyses establish no specific link between the appearance of blues, the average age of the parturients, the notion of previous blues, lacteal inhibition under bromocryptine. On the other hand, as stated in the literature, the appearance of postpartum blues is closely connected to previous PMS history, a painful delivery, or a psychologically difficult end of pregnancy. The originality of these results consists of two elements: (1) the correlation between the intensity of the blues and the weight gain during pregnancy; (2) a probable increase of neat weight, as the author has defined it, in the first days following postpartum. In a more general way, the role of weight variation stands out distinctly if the weight curves during gestation and the aggravation of psychiatric morbidity are observed in parallel. In the analysis of surgical blues by Illes, the severity of cluster scores of decrease of activity and of vigilance is noted, along with a culmination of the pathology on the second day (and not on the fifth day as in postpartum), which can justifiably be attributed to the suddenness and precocity of weight drop. Also related to the role of weight, numerous quasi-experimental, historical or clinical situations of weight loss and their psychiatric impact can be quoted. On another level, one should consider the decrease of activity in the approached situations. While basic metabolism increases during pregnancy progressively to 20%, delivery occurs through short but intense efforts. Postpartum implies a sudden deceleration in the course of which a physiological bradycardian phase around the fifth day can be underlined, as Magnin well described it. Some authors have positively correlated the blues to the intensity of labour, which corresponds to the degree of deceleration. In the same way, symptoms of sleep apnea syndrome have been linked to its fragmentation and to O₂ desaturation induced intellectual lapses, but an involvment of diurnal fits of sleepiness cannot be rejected. In the same spirit, the activating role, prior to their mood stabilizing effect, of antidepressants is well known and the role of the musculorespiratory peak of the convulsive crisis in sismotherapies can be looked into. Finally, the nearly constant positivity to the dexamethasone suppression test (DST) is a symptom devoid of causal participation. Since Carrol's study, the frequent positivity of this test has been observed in depressed subjects. But there are multiple causes for positivity, starting with immediate postpartum, to such an extent that some authors have considered the test as more characteristic of the postnatal period than of any psychic disorder. However, the frequency of denutrition complications in DST - positive cases (insufficiently controlled diabetics, alcoholics, the aged and postpartum of course) is to be underlined. Numerous Anglo-Saxon authors have moreover put the emphasis on the link between weight loss and DST positivity, although they underlined the limits of this explanation. This is how the variations of activity may constitute an additional etiology. Actually, even if Weitzman has privileged the level of hypnic inhibition in regulating plasma cortisol, the inverted correlation between the latter's variations and those of activity is indeed striking. In this hypothesis, depressed subjects’ curves would diverge mostly in the daytime to the extent of a difference in activity or a lack of activity more distinct than at night. To support this thesis, we will also point out the lower sensitivity of the test in ambulatory care, which may reflect a relative mildness of these cases but also a better activity, the standardization of the test when a depressive phase changes to excitement, the early standardization of the DST before the improvement of the mental state during sismotherapy or sleep deprivation. Weight loss and decrease in activity, which are of a physiological nature, would thus have a causal value, and the DST would only reflect these two elements. In the last part, the author engages in various physiopathological hypotheses and some commentaries. In his physiopathological hypotheses, he takes up Delay's idea of a regulating centre of mood, potentially subjected to variations of weight and activity. He mentions in particular that these variations may compensate each other, as with anorectics, or increase each other, as in postpartum blues. In his commentaries, he expands the previous ideas into his favourite theme, the deep motive for his research, which is the consubstantiality of acting and of being as the cornerstone of the holistic unity of the living, this concept being otherwise developed in an additional work quoted in reference.     

Training and assessment of laparoscopic skills.

Laparoscopic surgery is gaining popularity among the surgical community. While its prevalence expands, the need for reliable training and assessment tools is becoming increasingly important. Laparoscopic skills are not an innate behavior, nor can they be easily mimicked, and can only be acquired through hands-on training. A consensus exists among physicians that establishment and evaluation of technical skill in surgical training programs are inadequate and in need of improvement. A validated, reliable bench model that could train and assess could be standardized and provide numerous benefits including determination of which medical students should consider a career in surgery, valuable feedback to residents, a tracking mechanism of resident performance, a possible certification and recertification tool, and to allow for interinstitutional comparison. To this end, several potentially successful bench models testing dexterity, hand-eye coordination, and depth perception have been developed. A few models have been proven to be both valid and reliable indicators of technical skill. Although the future remains uncertain, enough groundwork has been laid to begin incorporating technical skill training and assessment into surgical training programs.     

Increased NoGo-anteriorisation in first-episode schizophrenia patients during Continuous Performance Test

OBJECTIVE: NoGo-stimuli during a Continuous Performance Test (CPT) activate prefrontal brain structures such as the anterior cingulate gyrus and lead to an anteriorisation of the positive electrical field of the NoGo-P300 relative to the Go-P300, so-called NoGo-anteriorisation (NGA). NGA during CPT is regarded as a neurophysiological standard index for cognitive response control. While it is known that patients with chronic schizophrenia exhibit a significant reduction in NGA, it is unclear whether this also occurs in patients undergoing their first-episode. Thus, the aim of the present study was to determine NGA in a group of patients with first-episode schizophrenia by utilizing a CPT paradigm. METHODS: Eighteen patients with first-episode schizophrenia and 18 matched healthy subjects were investigated electrophysiologically during a cued CPT, and the parameters of the Go- and NoGo-P300 were determined using microstate analysis. Low resolution tomography analysis (LORETA) was used for source determination. RESULTS: Due to a more posterior Go- and a more anterior NoGo-centroid, NGA was greater in patients than in healthy controls. LORETA indicated the same sources for both groups after Go-stimuli, but a more anterior source in patients after NoGo-stimuli. In patients P300-amplitude responses to both Go- and NoGo-stimuli were decreased, and P300-latency to NoGo-stimuli was increased. After the Go-stimuli false reactions and reaction times were increased in patients. CONCLUSIONS: Attention was reduced in patients with first-episode schizophrenia, as indicated by more false reactions, prolongation of reaction time, P300-latencies and by a decrease in P300-amplitude. Significantly however, the NGA and prefrontal LORETA-sources indicate intact prefrontal brain structures in first-episode schizophrenia patients. Previously described changes in this indicator of prefrontal function may be related to a progressive decay in chronic schizophrenia. SIGNIFICANCE: The results support the idea of a possible new biological marker of first episode psychosis, which may be a useful parameter for the longitudinal measurement of changing prefrontal brain function in a single schizophrenia patient.     

COPD患者IOS测定的阻力指标与FEV1%、FEV1/FVC相关性分析

目的对慢性阻塞性肺疾病(COPD)患者IOS测定的阻力指标与FEV1%、FEV1/FVC相关性进行分析.方法对100例COPD缓解期患者肺功能进行前瞻性分析研究.结果COPD患者1OS测定反映气道阻力参数指标Zrs、Fres、R5、X5、R5-R20与FEV1%、FEV1/FVC呈显著相关(P＜0.01),相关性为Fres＞R5-R20＞X5＞R5＞Zrs.R20与FEV1%、FEV1/FVC无显著相关.结论Fres、R5-R20可作为评定COPD患者气流阻塞及阻塞程度分级的指标.     

Ethical and metaethical criteria for an emerging technology: risk assessment

This paper examines ethical criteria for the shaping of an emergingtechnology applied internationally in environmental regulation:quantitative risk assessment-risk management. The role of thephysician in its application, especially in the genetic testingthat will be employed, underlines the importance of understandingthe nature and prospects for reshaping of this technology toenable ethical practice. The Cartesian or mechanistic model(which currently dominates the technology) excludes factorsof emotion, making the connection between assessment and managementunfruitful functionally and ethically, and makes the model unresponsiveto human needs. The emotional factors, nested and mediated inthe organic hierarchy of the ecologically-defined community,constitute key psychological, social, cultural and politicalelements of the total burden of risk. Ethical criteria consistentwith an open society are suggested for reshaping the model toenable effective management.     

特发性肺含铁血黄素沉着症二例

特发性肺含铁血黄素沉着症二例王永珍，李金鑫，刘建平，步惠英内蒙古自治区医院特发性肺含铁血黄素沉着症为一种少见的、病因尚不清楚的疾病，国内于１９６０年以来有近百例报导，其特征为肺毛细血管反复出血，渗出的血液发生溶血，含铁血黄素沉着于肺组织而起反应［１］...     

Quantification of motor deficit in Parkinson's disease with a motor performance test series

Summary It was the purpose of the present study to quantify the expected motor deficit in parkinsonian patients with the computer assisted Motor Performance Test Series (MPS), version 05.87 by Schuhfried (1987) and to examine which of the motor test variables found correlate at a significance level of p<0.01 with items of motor examination recorded at neurological examination and activities of daily living of the Unified Parkinson's Disease Rating Scale (UPDRS), version 3.0.38 patients with idiopathic Parkinson's disease (PD) stages I–IV according to Hoehn and Yahr, aged 41 to 73 years were studied. The study design, i.e. initial rating by the physician followed immediately by testing of motor function with MPS was strictly adhered to in each patient.Physician's rating of rigor and the scores of the semiquantitative tests (finger taps, hand movements and alternating movements) as expression of hypokinesia and the activities of daily living correlated with the 3 factors of the Motor Performance Test Series at a highly significant level independent of disease stage. Tremor is only partly and never significantly reflected in the motor data measured. Stages I–II and II–IV (Hoehn and Yahr) differ significantly in the representative data of the Motor Performance Test Series.The results of the study support the assumption that MPS is a valid instrument for quantitative measurement of the motor deficit in parkinsonian patients, but that only some subtests are pathognomonic.     

Reliability and validity of dyspnea measures in patients with obstructive lung disease

Dyspnea, the clinical term for shortness of breath, is the primary symptom and an important outcome measure in evaluations of patients with lung disease. It is a subjective symptom that has proved difficult to quantify. Many dyspnea measures are available, yet it is difficult, based on the existing literature, to determine the most reliable and valid. In this study, we evaluated 6 measures of dyspnea for reliability and validity: (a) Baseline Dyspnea Index (BDI) and Transition Dyspnea Index, (b) UCSD Shortness of Breath Questionnaire (SOBQ), (c) American Thoracic Society Dyspnea Scale, (d) Oxygen Cost Diagram, (e) Visual Analog Scale, and (f) Borg Scale. Subjects were 143 patients (74 women and 69 men) with obstructive lung disease, ages 40 to 86, FEV., 0.36 to 3.53 L, FVC 1.07 to 5.74 L. Dyspnea measures were assessed for test-retest reliability, internal consistency, interrater reliability, and construct validity (i.e.. correlations among dyspnea measures and correlations of dyspnea measures with exercise tolerance, health-related quality of life, lung function, anxiety, and depression). Results suggest that the SOBQ and BDI demonstrated the highest levels of reliability and validity among the dyspnea measures examined. This research was supported by University of California Tobacco Related Disease Research Program Grant 2RT026S, National Heart. Lung, and Blood Institute Grant HL 34732 to Robert M. Kaplan, and National Institutes of Health NHLBI Preventive Pulmonary Academic Award No. HL02215 to Andrew L. Ries.     

The categorical and dimensional models of endogenous depression

We calculated a Research Diagnostic Criteria (RDC) endogenous score for 257 depressed inpatients based on the number of endogenous criteria present. The distribution of RDC endogenous scores was unimodal. There was no association between endogenous scores and results of the Dexamethasone Suppression Test, or morbid risk for depression in the patients' first-degree relatives. The morbid risk for a family history of alcoholism tended to decrease with increasing endogenous scores, although a consistent steady decline was not observed. The results suggest that the RDC criteria do not fit either the categorical or dimensional model of endogenous classification. Potential sources of difficulty with the RDC endogenous criteria are discussed.