Transition de la pédiatrie à la médecine de l'adulte dans la mucoviscidose : quelles conséquences pour le patient ?

Question de recherche Transition de la pédiatrie à la médecine de l’adulte dans la mucoviscidose : quelles conséquences pour le patient ? Contexte La mucoviscidose est la maladie génétique la plus fréquente dans la population caucasienne, avec une prévalence estimée à une naissance sur 3’631 en Suisse en 2016. L’espérance de vie à la naissance de ces enfants a considérablement augmenté, passant de 5 ans en 1960 à plus de 40 ans dans les années 2000. Auparavant létale au stade infantile, la mucoviscidose est désormais devenue une maladie chronique de l’adulte : ainsi, le nombre de patients suivis en médecine adulte égale maintenant le nombre suivi en pédiatrie. Dès leur arrivée à l’adolescence, les patients doivent passer d’une prise en charge pédiatrique à la médecine adulte, l’enjeu étant que cette transition ne prétérite ni leur prise en charge, ni l’évolution de la maladie. Objectifs Le but de l’étude est d’évaluer l’impact de cette transition sur les aspects médicaux et psycho-sociaux de cette maladie. Son objectif est de présenter un tableau de l’état de santé des patients au moment de la transition et de comparer ces données à celles obtenues 2 ans après la transition, afin d’analyser l’évolution de la maladie. Les différences de prise en charge entre la médecine pédiatrique et la médecine adulte sont également inclues. Méthodologie Ce travail est une étude rétrospective, mono-centrique et comparative. Les quinze derniers patients ayant transité à la consultation adulte de mucoviscidose du CHUV ont été inclus dans l’étude, sous réserve que le diagnostic ait été posé en pédiatrie, et qu’ils aient été suivis au moins pendant 2 ans en pédiatrie avant la transition et pendant 2 ans en médecine adulte après. Les variables comparées sont : l’état des systèmes touchés par la mucoviscidose dont la nutrition, les systèmes digestifs, endocriniens, ORL et respiratoires. Sont également inclus la médication, la compliance, la fréquence et diversité du suivi, ainsi que la formation et profession. Résultats Cinquante-trois pourcents des patients infléchissent leur courbe de croissance staturo-pondérale au cours des 2 ans qui suivent la transition. Les facteurs influençant négativement cette courbe sont le fait de présenter, au moment de la transition, une atteinte hépatique sévère (cirrhose ou greffe hépatique) et/ou un diabète. Quarante pourcents des patients péjorent leur degré d’obstruction pulmonaire dans les 2 ans post- transition ; 60% des patients sont sous corticoïdes inhalés au moment de la transition versus 33% 2 ans après ; 73% des patients ont un suivi régulier au moment de la transition versus 47% 2 ans après ; 33% des patients ont une bonne compliance au moment de la transition versus 27% 2 ans après ; aucun patient sans emploi ou sans formation au moment de la transition versus 33% 2 ans après. Conclusions La transition ne semble pas influencer l’atteinte hépatique, pancréatique, intestinale ou ORL. Les prescriptions de médicaments entre la pédiatrie et la médecine adulte sont similaires, hormis pour les corticoïdes inhalés. Durant les 2res années après la transition, l’état nutritionnel et l’atteinte respiratoire se péjorent parallèlement à une diminution de la régularité et de la diversité du suivi médical. L’intégration dans le milieu professionnel qui a lieu dans les 1res années post transition est moins bonne que l’intégration dans le milieu scolaire lorsque le patient est suivi en pédiatrie. Ces points devraient faire l’objet d’une attention et d’une prise en charge particulière

Development of a duodenal gallstone ileus with gastric outlet obstruction (Bouveret syndrome) four months after successful treatment of symptomatic gallstone disease with cholecystitis and cholangitis: a case report

<p>Abstract</p> <p>Introduction</p> <p>Cases of gallstone ileus account for 1% to 4% of all instances of mechanical bowel obstruction. The majority of obstructing gallstones are located in the terminal ileum. Less than 10% of impacted gallstones are located in the duodenum. A gastric outlet obstruction secondary to a gallstone ileus is known as Bouveret syndrome. Gallstones usually enter the bowel through a biliary enteral fistula. Little is known about the formation of such fistulae in the course of gallstone disease.</p> <p>Case presentation</p> <p>We report the case of a 72-year-old Caucasian woman born in Germany with a gastric outlet obstruction due to a gallstone ileus (Bouveret syndrome), with a large gallstone impacted in the third part of the duodenum. Diagnostic investigations of our patient included plain abdominal films, gastroscopy and abdominal computed tomography, which showed a biliary enteric fistula between the gallbladder and the duodenal bulb. Our patient was successfully treated by laparotomy, duodenotomy, extraction of the stone, cholecystectomy, and resection of the fistula in a one-stage surgical approach. Histopathological examination showed chronic and acute cholecystitis, with perforated ulceration of the duodenal wall and acute purulent inflammation of the surrounding fatty tissue. Four months prior to developing a gallstone ileus our patient had been hospitalized for cholecystitis, a large gallstone in the gallbladder, cholangitis and a small obstructing gallstone in the common biliary duct. She had been treated with endoscopic retrograde cholangiopancreatography, endoscopic biliary sphincterotomy, balloon extraction of the common biliary duct gallstone, and intravenous antibiotics. At the time of her first presentation, abdominal ultrasound and endoscopic examination (including esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography) had not shown any evidence of a biliary enteral fistula. In the four months preceding the gallstone ileus our patient had been asymptomatic.</p> <p>Conclusion</p> <p>In patients known to have gallstone disease presenting with symptoms of ileus, the differential diagnosis of a gallstone ileus should be considered even in the absence of preceding symptoms related to the gallbladder disease. Gallstones large enough to cause intestinal obstruction usually enter the bowel by a biliary enteral fistula. During the formation of such a fistula, patients can be asymptomatic.</p

Efficacy of an adjunctive brief psychodynamic psychotherapy to usual inpatient treatment of depression: rationale and design of a randomized controlled trial.

BACKGROUND: A few recent studies have found indications of the effectiveness of inpatient psychotherapy for depression, usually of an extended duration. However, there is a lack of controlled studies in this area and to date no study of adequate quality on brief psychodynamic psychotherapy for depression during short inpatient stay exists. The present article describes the protocol of a study that will examine the relative efficacy, the cost-effectiveness and the cost-utility of adding an Inpatient Brief Psychodynamic Psychotherapy to pharmacotherapy and treatment-as-usual for inpatients with unipolar depression. METHODS/DESIGN: The study is a one-month randomized controlled trial with a two parallel group design and a 12-month naturalistic follow-up. A sample of 130 consecutive adult inpatients with unipolar depression and Montgomery-Asberg Depression Rating Scale score over 18 will be recruited. The study is carried out in the university hospital section for mood disorders in Lausanne, Switzerland. Patients are assessed upon admission, and at 1-, 3- and 12- month follow-ups. Inpatient therapy is a manualized brief intervention, combining the virtues of inpatient setting and of time-limited dynamic therapies (focal orientation, fixed duration, resource-oriented interventions). Treatment-as-usual represents the best level of practice for a minimal treatment condition usually proposed to inpatients. Final analyses will follow an intention-to-treat strategy. Depressive symptomatology is the primary outcome and secondary outcome includes measures of psychiatric symptomatology, psychosocial role functioning, and psychodynamic-emotional functioning. The mediating role of the therapeutic alliance is also examined. Allocation to treatment groups uses a stratified block randomization method with permuted block. To guarantee allocation concealment, randomization is done by an independent researcher. DISCUSSION: Despite the large number of studies on treatment of depression, there is a clear lack of controlled research in inpatient psychotherapy during the acute phase of a major depressive episode. Research on brief therapy is important to take into account current short lengths of stay in psychiatry. The current study has the potential to scientifically inform appropriate inpatient treatment. This study is the first to address the issue of the economic evaluation of inpatient psychotherapy. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry (ACTRN12612000909820)

Trade-offs between vegetative growth and acorn production in Quercus lobata during a mast year: the relevance of crop size and hierarchical level within the canopy

The concept of trade-offs between reproduction and other fitness traits is a fundamental principle of life history theory. For many plant species, the cost of sexual reproduction affects vegetative growth in years of high seed production through the allocation of resources to reproduction at different hierarchical levels of canopy organization. We have examined these tradeoffs at the shoot and branch level in an endemic California oak, Quercus lobata, during a mast year. To determine whether acorn production caused a reduction in vegetative growth, we studied trees that were high and low acorn producers, respectively. We observed that in both low and high acorn producers, shoots without acorns located adjacent to reproductive shoots showed reduced vegetative growth but that reduced branch-level growth on acorn-bearing branches occurred only in low acorn producers. The availability of local resources, measured as previous year growth, was the main factor determining acorn biomass. These findings show that the costs of reproduction varied among hierarchical levels, suggesting some degree of physiological autonomy of shoots in terms of acorn production. Costs also differed among trees with different acorn crops, suggesting that trees with large acorn crops had more available resources to allocate for growth and acorn production and to compensate for immediate local costs of seed production. These findings provide new insight into the proximate mechanisms for mast-seeding as a reproductive strategy

Outcome of crisis intervention for borderline personality disorder and post traumatic stress disorder: a model for modification of the mechanism of disorder in complex post traumatic syndromes

<p>Abstract</p> <p>Background</p> <p>This study investigates the outcome of crisis intervention for chronic post traumatic disorders with a model based on the theory that such crises manifest trauma in the present. The sufferer's behavior is in response to the current perception of dependency and entrapment in a mistrusted relationship. The mechanism of disorder is the sufferer's activity, which aims to either prove or disprove the perception of entrapment, but, instead, elicits more semblances of it in a circular manner. Patients have reasons to keep such activity private from therapy and are barely aware of it as the source of their symptoms.</p> <p>Methods</p> <p>The hypothesis is that the experimental intervention will reduce symptoms broadly within 8 to 24 h from initiation of treatment, compared to treatment as usual. The experimental intervention sidesteps other symptoms to engage patients in testing the trustworthiness of the troubled relationship with closure, thus ending the circularity of their own ways. The study compares 32 experimental subjects with 26 controls at similar crisis stabilization units.</p> <p>Results</p> <p>The results of the Brief Psychiatric Rating Scale (BPRS) supported the hypothesis (both in total score and for four of five subscales), as did results with Client Observation, a pilot instrument designed specifically for the circular behavior targeted by the experimental intervention. Results were mostly non-significant from two instruments of patient self-observation, which provided retrospective pretreatment scores.</p> <p>Conclusions</p> <p>The discussion envisions further steps to ascertain that this broad reduction of symptoms ensues from the singular correction that distinguishes the experimental intervention.</p> <p>Trial registration</p> <p>Protocol Registration System NCT00269139. The PRS URL is <url>https://register.clinicaltrials.gov</url></p

Defensive responses by a social caterpillar are tailored to different predators and change with larval instar and group size

Gregariousness in animals is widely accepted as a behavioral adaptation for protection from predation. However, predation risk and the effectiveness of a prey’s defense can be a function of several other factors, including predator species and prey size or age. The objective of this study was to determine if the gregarious habit of Malacosoma disstria caterpillars is advantageous against invertebrate natural enemies, and whether it is through dilution or cooperative defenses. We also examined the effects of larval growth and group size on the rate and success of attacks. Caterpillars of M. disstria responded with predator-specific behaviors, which led to increased survival. Evasive behaviors were used against stinkbugs, while thrashing by fourth instar caterpillars and holding on to the silk mat by second instar caterpillars was most efficient against spider attacks. Collective head flicking and biting by groups of both second and fourth instar caterpillars were observed when attacked by parasitoids. Increased larval size decreased the average number of attacks by spiders but increased the number of attacks by both stinkbugs and parasitoids. However, increased body size decreased the success rate of attacks by all three natural enemies and increased handling time for both predators. Larger group sizes did not influence the number of attacks from predators but increased the number of attacks and the number of successful attacks from parasitoids. In all cases, individual risk was lower in larger groups. Caterpillars showed collective defenses against parasitoids but not against the walking predators. These results show that caterpillars use different tactics against different natural enemies. Overall, these tactics are both more diverse and more effective in fourth instar than in second instar caterpillars, confirming that growth reduces predation risk. We also show that grouping benefits caterpillars through dilution of risk, and, in the case of parasitoids, through group defenses. The decreased tendency to aggregate in the last larval instar may therefore be linked to decreasing predation risk

Spotlight on Japanese physicians: An exploration of their professional experiences elicited by means of narrative facilitators.

While investigation of physicians' work experience is often limited to issues of satisfaction or burnout, a broader view of their experiences is lacking. To explore professional experiences, we asked Japanese physicians (N = 18, 12 men and 6 women) of a general hospital to react to so-called "narrative facilitators". The narrative facilitators - inspired by clinical psychology, visual sociology and purpose-designed techniques - oriented physicians' narratives towards clinical practise, relationship with peers and context. Transcribed interviews were subject to thematic analysis. The thematic analysis of participants' narratives revealed a lonely physician with a tough job, torn between the ideal of patient-centred care and a clinical reality, which limits these aspirations. Patients emerged as anxious and burdensome consumers of medicine. Feeling neither supported by peers nor the institution, physicians also perceived the society as somewhat negligent, delegating its problem to medicine. Communication difficulties, with patients and peers, and the absence of joyful aspects of the profession constituted fundamental elements of their narratives. Comprehensive investigation of physicians' lived professional experience could become a key to conceive ways to support them