Détection et intervention précoce : un nouveau paradigme

Treating psychotic disorders in their earliest stages has become a focus for research and clinical care worldwide. Specialized programs for early detection and early intervention in psychosis in adolescents and young adults have developed in many countries and have shown their effectiveness. After a first psychotic episode, the quality of functional remission is best when specialized care is proposed at the earliest. Moreover, the period preceding the emergence of a constituted disorder (“prodromal”) is a period of opportunity for preventive interventions that reduces the risk of transition to psychosis. These programs have further shown that the evolution of a mental state at-risk of psychotic transition, presenting some symptoms, towards a full-blown psychotic episode or from a psychotic episode to a chronic schizophrenic disorder are not inevitable. France has not yet developed these practices at the national level, but some initiatives are emerging and the French Transition network, within the Institute of Psychiatry, participates in the French-speaking branch of IEPA. The deployment of such programs is a real societal challenge and represents a paradigm shift: it questions the practices and the organization of the healthcare system, but also the way health care professionals and the general public look at these diseases.     

Le travail des centres maternels auprès de jeunes mères célibataires à haut risque

Single mothers represent about a quarter of French single-parent families. Within the population of single mothers, those who seek shelter in institutions such as maternity homes constitute a high-risk group. Grounded on two field studies with this population, and on our own clinical experience of joint psychotherapy of these mothers and their infant, this paper discusses the complex work realized by maternity homes. It emerges that maternity homes, as institutions, are brought to play, on the one hand, a maternal role that includes the holding, a “protective shield” role against excitation, and the safety of the mother to be and her infant. In this protected and stable environment, the mother will be able to develop her competencies to raise her infant and to build an affective bond with him. On the other hand, maternity homes should also act as a “father”, mediating the mother-infant relationship and, in doing that, they have to engage, as much as possible, the infant's father himself. In this “paternal role”, the institution should open the mother and her infant to the outside world, (re)integrating them in a social and affective network, and preventing them to relapse into the isolation or the multiple deprivations experienced by the preceding generations.     

Stillbirths and early neonatal mortality in rural Northern Ghana

Objective To calculate perinatal mortality (stillbirth and early neonatal death: END) rates in the Upper East region of Ghana and characterize community‐based stillbirths and END in terms of timing, cause of death, and maternal and infant risk factors. Methods Birth outcomes were obtained from the Navrongo Health and Demographic Surveillance System over a 7‐year period. Results Twenty thousand four hundred and ninty seven pregnant women were registered in the study. The perinatal mortality rate was 39 deaths/1000 deliveries, stillbirth rate 23/1000 deliveries and END rates 16/1000 live births. Most stillbirths were 31 weeks gestation or less. Prematurity, first‐time delivery and multiple gestation all significantly increased the odds of perinatal death. Approximately 70% of END occurred during the first 3 postnatal days, and the most common causes of death were birth asphyxia and injury, infections and prematurity. Conclusion Stillbirths and END remain a significant problem in Navrongo. The main causes of END occur during the first 3 days and may be modifiable with simple targeted perinatal policies.     

Réhabilitation précoce après césarienne programmée : enquête de pratique auprès des maternités des régions Provence - Alpes - Côte d’Azur et Île-de-France

Aims

Although most components of an enhanced recovery programme (ERP) can be applied to caesarean delivery, it is unknown if their implementation is large in France.

Type of study

Structured interview by telephone or e-mailing of an anaesthetist to describe usual perioperative practice in two French regions (Provence - Alpes - Côte d’Azur [PACA] and Île-de-France [IDF]).

Methods

Questionnaire related to scheduled caesarean delivery.

Results

Response rate 74% (111/149 maternity units). Multimodal analgesia was almost universally applied and intrathecal/epidural morphine used by 86% of respondents. Oral administration of analgesic drugs was started before h24 in 50% of responding units and immediately after delivery in 7% of them. The urinary catheter was withdrawn after h24 in 71% of responding centres. Women were allowed to drink between h4 and h6 (60%), in an unlimited amount (79%). The first meal was authorised after h6 (89%) but before h24 (65%) or after recovery of bowel function (13%). Oxytocin was used in 69% of respondents and maintained postoperatively for 12 to 24 hours (70% of oxytocin users). Carbetocin was used in the remaining 31%, usually without any maintenance oxytocic drug. Attributing one point to each major component of the ERP protocol (0–6), the median value was 3 (2–4). An ERP protocol was available in 14% of responding units and was associated with a shorter duration of intravenous and urinary catheters use.

Conclusion

The study shows that the components of an ERP are insufficiently implemented in France after caesarean delivery. Moreover, significant heterogeneity exists between maternity units and among regions.     

Isolated fracture of the capitate with rotation of the proximal fragment. Case report

A case of capitate fracture in a 28-year-old man, with a 180-degree rotation (volar dislocation) of the proximal fragment is reported. Due to a late diagnosis, the patient presented 2 weeks after trauma. Open reduction and internal fixation with Kirschner wires provided good bone alignment, uneventful healing and a good range of wrist motion was achieved. The authors remind the reader the possibility of capitate fracture, a rare but troublesome event among wrist traumas, requiring a prompt diagnosis and treatment to relief important wrist pain and to restore function. Moreover, in consideration of important vascular complications, producing non-union and arthritis, the emerging role of imaging in detecting even minor signs of bone necrosis, leading to correct surgical indications, has to be taken into account.     

Timing of tracheostomy and outcome of patients requiring mechanical ventilation

Objectives

To assess the impact of tracheostomy timing on outcome of critically ill patients requiring mechanical ventilation (MV).

Study design

Retrospective clinical study in a twelve beds intensive care unit (ICU).

Patients and methods

From January 2001 to June 2005, patients under MV who received tracheostomy were divided into 2 groups: early tracheostomy group when tracheostomy was performed before or on day 7 and late tracheostomy group when it was performed thereafter. We compared prevalence of nosocomial pneumonia, length of sedation, lengths of MV, length of stay in ICU, weaning from MV and mortality rates between the 2 groups.

Results

During this period of 4 years and half, 112 patients underwent tracheostomy, 62 of whom had early tracheostomy and 50 had late tracheostomy. Early tracheostomy was associated with significant reduction of length of sedation (10 ± 3 vs 17 ± 5 days, P < 0.001), length of MV (21 ± 19 vs 29 ± 17 days, P = 0.02) and length of stay in ICU (33 ± 22 vs 42 ± 18 days, P = 0.042). There were no differences in prevalence of pneumonia (21% for early tracheostomy group vs 31% for late tracheostomy group, P = 0, 13), weaning from MV (50 vs 36%, P = 0.19), and mortality rates between the 2 groups (38 vs 54%, P = 0.15).

Conclusion

This study demonstrated that early tracheostomy (≤ 7 days), was associated with shorter length of sedation, shorter duration of MV and shorter ICU length of stay, without affecting weaning from MV, prevalence of nosocomial pneumonia or survival.     

Système d'acquisition de réponses évoquées cérébrales et de pilotage de stimulation à base de microprocesseur

The microprocessor-based system is designed to study the cerebral responses (average evoked potentials) to sensory stimuli, and especially to auditory stimuli in real time. A stimulator with digital commands is controlled by the computer module. Up to eight different kinds of stimulations can be defined by the operator before the experiment. Their order and frequency may be fixed or random. Up to eight e.e.g. channels can be analysed simultaneously. While the data are being processed, the response on one of the eight channels is displayed on the screen of a cathode-ray tube. After the processing, all the responses can be drawn automatically on an analogXY plotting recorder, together with the relevant commentaries. The system also has other functions, such as automated calibration of each e.e.g. channel, checking of the quality of the signals before averaging, automated correction of the baseline shift and the possibility of extracting the short latency evoked-potential responses.     

Conséquences tardives d'une stimulation précoce de l'hypothalamus latéral sur l'apprentissage et l'inversion d'une discrimination lumière-obscurité

The reported experiments point out the effect of an imposed electrical stimulation of the lateral hypothalamus in 15 days old rats on the acquisition and reversal of a food reinforced light/dark discrimination, performed between the 42nd and 82nd days of age. In both acquisition and reversal, stimulated animals showed an improvement of performances, compared to implanted and non-implanted control animals.