ABSTRACT
La prise en soins des patients présentant des troubles de déglutition est complexe et requiert des compétences pluriprofessionnelles. La clinique St-Yves (Rennes) a ouvert en 2012 un hôpital de jour (HDJ) articulant évaluation diététique, orthophonique et médicale. La particularité consiste en des essais alimentaires réalisés en direct, grâce aux préparations préalablement commandées en cuisine. Ces essais permettent de dépister la nature des troubles, proposer des adaptations de texture et lutter contre la dénutrition. À l'annonce du premier confinement lié à l'épidémie de COVID-19, nombreux sont les professionnels de santé qui ont dû repenser leur organisation de travail. La télé-orthophonie a fait son apparition, notamment dans le cadre de la rééducation de troubles des apprentissages, de retard de parole/langage ou encore de troubles phasiques, mais reste peu employée pour le bilan et la rééducation des dysphagies. Pourtant, il s'agit d'une problématique majeure, notamment chez les personnes âgées, pouvant entraîner un état de dénutrition (dont la prévalence est estimée de 15 à 38 % en institution). Certains EHPAD rencontrent des difficultés pour l'évaluation et la prise en soin des troubles de la déglutition de certains des résidents. Afin de répondre à leur demande (EHPAD de Montfort-Sur-Meu et Janzé ;département d'Ille et Vilaine) et pallier l'absence d'orthophonistes dans ces structures, un télé-HDJ de déglutition a été ouvert. Ce téle-HDJ a été dupliqué sur le modèle existant avec la particularité d'associer l'IDE et la diététicienne de l'EHPAD, le médecin et l'orthophoniste étant à distance. Le patient se situe lui au sein de l'EHAPD. Réalisation de la télé-consultation médicale : mesures anthropométriques, cinétique du poids, évaluation de l'alimentation artificielle/des traitements, suivi du transit, de la sonde d'alimentation... Le bilan orthophonique consiste en une évaluation des praxies bucco-pharyngo-laryngées sensorimotrices réalisées par l'IDE sur indication de l'orthophoniste et d'échelles d'autoévaluation. Des essais alimentaires sont réalisés en direct, grâce aux préparations préalablement commandées en cuisine afin de dépister la nature des troubles et de proposer des adaptations possibles. Le matériel d'aspiration est à proximité, permettant d'assurer une sécurité supplémentaire. Enfin, le patient assiste à la synthèse pluriprofessionnelle lors de laquelle des objectifs personnalisés sont remis. Depuis mai 2020, 14 patients ont été pris en charge (1 à 4 HDJs/patients). La moyenne d'âge était de 79,7 ans (85 % de patients âgés de plus de 70 ans). Les maladies neurologiques représentaient 50 % des diagnostics. L'indice de masse corporelle (IMC) moyen était de 25,8 avec une prévalence de la dénutrition de 28 % (diagnostiquée avec l'IMC ou la perte de poids) et la présence d'une nutrition entérale pour 4 d'entre eux (28 %). Six patients (42 %) ont nécessité une rééducation orthophonique, les autres prises en charge consistant en une réassurance des équipes pour la réintroduction alimentaire. Huit patients (57 %) ont reçu un enrichissement alimentaire avec ± compléments nutritionnels oraux ;deux patients ont nécessité une évaluation supplémentaire en présentiel (14 %) en raison d'une indication à une nutrition entérale. Quatre patients ne présentaient aucun trouble de déglutition. Les téléconsultations réalisées dans le cadre de l'évaluation de la déglutition, de l'état nutritionnel ainsi que de la prévention et du traitement de la dénutrition peuvent s'avérer une solution à part entière permettant d'associer les aidants habituels, pour les résidents d'EHPAD. Elles permettent de réduire le déplacement du patient, mais nécessitent parfois un recours plus approfondi en présentiel (14 %). Il reste donc à appréhender les bénéfices thérapeutiques et limites éventuelles de ce format de consultation, en comparaison avec une modalité classique, dans le ca re de l'évaluation des troubles de la déglutition chez les personnes âgées. (French) [ FROM AUTHOR] Copyright of Nutrition Clinique et Métabolisme is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)
ABSTRACT
Background. Environmental factors such as infections and vaccines are known to trigger dermatomyositis (DM), and during the recent SARS-CoV-2 pandemic this has become even clearer. SARS-CoV-2 infection may share features with anti-MDA5 DM, such as rapidly progressive lung involvement, cutaneous lesions and cytokine release syndrome. A few case reports of DM following SARSCoV-2 vaccination have been published, suggesting the onset of an aberrant immune response leading to DM with specific autoantibody signatures and severe organ impairment. Methods. Clinical and laboratory data of the 2 case reports were obtained from electronic clinical charts in Humanitas Research Hospital (Rozzano, Milan, Italy). Autoantibody analysis was performed by protein-immunoprecipitation for anti-MDA5 and immunoblot for anti-Ro52 and TIF1gamma antibodies as per protocol. Results. Case report 1 is a 71-year-old woman who developed fever, cough, and anosmia, which resolved spontaneously in two weeks, but did not undergo a nasopharyngeal swab, while her relatives were diagnosed with SARS-CoV-2 infection. When symptoms improved, she developed arthralgia and skin lesions on her face, chest, and hands for which she started topical treatment, with negative SARSCoV-2 nasopharyngeal swab and positive serum test for IgG against SARS-CoV-2 spike protein. For the persistence of the skin rash and arthralgia, she was admitted to our Department in March 2021. Blood tests showed mild elevation of C reactive protein (2.1 mg/L -normal value NV<5), aspartate (84 UI/L) and alanine aminotransferase (133 UI/L -NV<35), ferritin (595 ng/ml -NV<306), troponin I (19 ng/L -NV<14), and BNP (251 pg/ml -NV<100) with normal complete blood cell count, creatine kinase, C3 and C4. IgG antibodies for SARS-CoV-2 spike protein were confirmed to be elevated (96 AU/ml -NV<15). Autoantibodies associated with connective tissue diseases were tested and only anti-MDA5 antibodies were positive at immunoprecipitation. A punch biopsy of a Gottron-like lesion on the left hand showed leukocytoclastic vasculitis. We observed reduced capillary density with neoangiogenesis and ectasic capillaries at the nailfold capillaroscopy. EKG and ecocardiography were normal, while cardiac magnetic resonance detected abnormalities in the parametric sequences, consistent with signs of previous myocarditis. A lung CT scan revealed pulmonary emphysema while respiratory function tests demonstrated reduced volumes (FVC 82%, FEV1 64%, inadequate compliance CO diffusion test). Based on the biochemical and clinical findings, a diagnosis of anti-MDA5-associated DM with skin and heart involvement was made and treatment with low-dose methylprednisolone (0.25 mg/kg daily) and azathioprine 100 mg was started, then switched to mycophenolate because not effective on skin lesions. Case report 2 is an 84-year-old woman with history of colon cancer (surgical treatment) and oral lichen treated with low doses steroids in the last 2 years. After the 2nd dose of SARS-CoV-2 mRNA vaccination, in March 2021 she developed skin rash with V-sign, Gottron's papules, periungueal ulcers, muscle weakness and fatigue, thus she performed a rheumatologic evaluation. Blood tests showed mild elevation of creatine kinase (484 UI/L, NV <167), CK-MB (9.6ng/ml, NV <3.4), BNP (215 pg/ml -NV<100) with normal values of complete blood cell count, C3 and C4. Anti-Ro52kDa and TIF1gamma were positive at immunoblot, thus we confirmed a diagnosis of DM. The clinical evaluation also showed active scleroderma pattern at nailfold capillaroscopy, normal echocardiography, bronchiectasia but not interstitial lung disease at lung CT, and normal respiratory function tests (FVC 99%, FEV1 99%, DLCO 63%, DLCO/VA 81%). A PET-CT scan was performed to exclude paraneoplastic DM, and treatment with steroids and mycophenolate was started. Conclusions. SARS-CoV-2 may induce mechanisms for escaping the innate immunity surveillance and causing autoimmune diseases, but more clinical and functional studies are needed to demonstrate this possible association.
ABSTRACT
BACKGROUND: Adjustment disorders are now primary diagnoses in the trauma and stressrelated disorders section of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Adjustment disorder with anxiety (AjDA) is the development of emotional or behavioral symptoms considered excessive in response to stressful events, significantly impairing a person's ability to function in social, occupational, and/ or other situations. Traumatic experiences related to the COVID-19 pandemic may have increased rates of adjustment disorders, especially among those whose life routines were disrupted by pandemic-associated stress and anxiety. PH94B (3b-hydroxy-androsta-4,16-dien-ol) has shown rapid-onset efficacy in the treatment of social anxiety disorder (Liebowitz et al. Am J Psychiatry. 2014). PH94B is a neuroactive steroid administered as a nasal spray that engages olfactory chemosensory neurons, activating subsets of olfactory bulb neurons that project directly to the limbic amygdala regulating fear and anxiety circuits. OBJECTIVE: To assess the efficacy, safety, and tolerability of PH94B in adults with AjDA. METHODS: This is an exploratory, phase 2A, randomized, double-blind, 4-week, placebo-controlled, 2-arm study in adults with AjDA. The primary outcome is change from baseline to week 4 in the Hamilton Anxiety Rating Scale (HAM-A) total score after intranasal administration of PH49B 4 times daily vs placebo. Patients with a DSM-5 diagnosis of AjDA confirmed by the Mini-International Neuropsychiatric Interview (MINI) with Adjustment Disorders Module and a clinician-rated HAM-A score of ≥20 at screening (Visit 1), with ≤15% decrease at baseline (Visit 2, randomization) are eligible for inclusion. Secondary outcomes include change from baseline to week 4 in the Adjustment Disorder New Module Scale (ADNM), the International Adjustment Disorder Questionnaire (IADQ), the Clinical Global Impression of Improvement (CGI-I), and the Patient Global Impression of Change (PGI-C). Change from baseline in the Hamilton Depression Rating Scale (HAM-D) was exploratory. RESULTS: A total of 40 patients will be randomized (1:1 drug to placebo). The study design features the use of the ADNM and IADQ, newly developed according to ICD-11 criteria for evaluation of AjDA. While both are validated, neither has been tested in placebo-controlled clinical trials. Both scales begin with a list of stressors (18 for ADNM and 9 for IADQ);a yes answer to any 1 stressor triggers a series of questions about the frequency and duration of a patient's reaction to the stressor (ADNM) or quantifies symptoms in response to the stressor (IADQ). CONCLUSIONS: Anxiety disorders are the most prevalent psychiatric disorders and a leading cause of disability. Anxiety and impaired functioning are increasing, particularly in response to the COVID-19 pandemic, and no pharmacologic treatment is currently approved by the FDA for AjDA. PH94B, an investigational pherine nasal spray, is also being studied for treatment of other anxiety-related disorders.
ABSTRACT
OBJECTIVE: The effects of COVID-19 seem to extend beyond the physical pain and is showing psychiatric implications as well. Moreover, psychopathological implications seem to last also after patients' discharge. Our goal is to investigate the psychological impact and psychopathological outcome of patients affected by COVID-19. PATIENTS AND METHODS: We have engaged 34 patients with COVID-19 conditions [eight of them were healthcare workers patients (HCW)] hospitalized at "Policlinico Gemelli Foundation" of Rome, Italy. All patients were evaluated through the Impact of Event Scale-Revised (IES-R) and the Symptom Checklist 90-R (SCL-90-R) first, during their hospitalization (baseline), and then, after 4 months from hospital discharge (follow-up), through phone interviews. RESULTS: At baseline, 82% of patients revealed from mild to severe psychological impact of COVID-19, according to the IES-R. At follow-up, the mean IES-R total score was significantly decreased (p<0.001) even if almost half (46.6%) of our cohort still showed it. HCW patients showed a significantly higher score than other patients at IES-R scale, both at baseline (p=0.005) and at follow-up (p<0.001). Moreover, at 4 months from discharge, they showed a significantly higher percentage of moderate and severe distress (p=0.015). In addition to this, at follow-up, our cohort of patients showed an increase of anxiety symptoms, even if not significant compared to baseline (46.7% vs. 35.3% respectively; p=1.000), and HCW patients suffered more sleep disorders (p=0.019) and anxiety symptoms (p=0.019) compared to other patients. CONCLUSIONS: We indicate the importance of assessing psychopathology of COVID-19 survivors, monitoring their changes over time, and providing psychological support to improve their psychological well-being.