[Interpersonal psychotherapy from research to practice]. / La thérapie interpersonnelle de la recherche à la pratique.

THEORETICAL BACKGROUND: Interpersonal therapy (IPT) is a brief, structured psychotherapy initially intended to treat adult depression that was developed in the 1970s and manualized in 1984 by G. Klerman and his team. Two main theories served as a basis for its design: Bowlby's attachment theory and communication theory. Klerman theorized that tensions and problems in interpersonal relationships (i.e. disputes) cause psychological distress in vulnerable individuals that may lead to a major depressive episode. Clinical and epidemiological studies have shown that an insecure attachment style is strongly associated with lifetime depression. Severe depressive episodes have been correlated with avoidant attachment in women. THERAPY STRUCTURE AND TECHNIQUES: IPT is based on the hypothesis that recent or ongoing disturbances in interpersonal relationships either trigger or follow the onset of mood disorder. In practice, IPT assists patients in analysing their interpersonal relationship modes, correlating their relational states with their mood and in learning to use better communication. Resolving difficulties in interpersonal relationships through the use of better communication skills promotes the improvement of depressive symptoms. Klerman identified four interpersonal areas that seem to be highly correlated with depressive episodes: grief (a close and important personal relation who has died), interpersonal disputes (conflicts with significant people such as a spouse or another close family member), role transition (significant life changes such as retirement, parenthood or chronic and invalidating illness) and interpersonal deficits (patients who have limited social contacts and few interpersonal relations). Classically, IPT is planned around 12-16 weekly sessions. During the initial sessions, the therapist will explore all existing interpersonal relations and any significant dysfunctions, both recent and ongoing. Following this interview, the area the patient considers as driving the current depressive episode will be designated as the focus of therapy. Evaluation of depressive symptoms by a quantitative measure (i.e. Visual Analogue Scale) and qualitative measures (activity, pleasure, quality of life) reoccurs at each session. During the intermediate sessions, therapy uses current situations and events in the designated area that particularly affect the patient's mood. Coping, communication and decision-making skills are gradually improved through a number of techniques. These include non-directive and directive exploration, clarification, encouragement of affect, and communication analysis. The therapeutic relationship is empathetic and encouraging of all progress the patient makes. The final phases close the therapy and help the patient to plan future actions and improvements. CLINICAL TRIALS OF IPT AND DEVELOPMENTS: Several controlled clinical trials in adult populations have demonstrated the efficacy of IPT in treating Major Depressive Disorder (initial and recurrent episodes). It has been recommended as an appropriate treatment option in several guidelines. It can be provided in individual, couple or group formats. There remains an ongoing discussion of the efficacy of monthly maintenance sessions in recurrent depression. Since its conception, clinical trials have explored its use in specific populations such as adolescents and the elderly. IPT has also been the object of trial in other disorders such as post-partum depression, bipolar disorder, social phobia and eating disorders. CONCLUSION: This article reviews the basic principles and objectives of this therapeutic model. Theoretical concepts and results from research are also discussed. The approach is briefly described and the various therapeutic phases are discussed. Clinical trials have shown that IPT is effective in treating major depressive disorder in a wide variety of populations. Further trials are necessary to determine its efficacy in other psychiatric disorders.

[Benefits in reducing alcohol consumption: how nalmefene can help]. / Bénéfices de la réduction de la consommation d'alcool: comment le faire avec nalméfène.

Alcohol consumption represents a significant factor for mortality in the world: 6.3% in men and 1.1% in women. Alcohol use disorder is also very common: 5.4% in men, 1.5% in women. Despite its high frequency and the seriousness of this disorder, only 8% of all alcohol-dependents are ever treated. Recent meta-analyses have shown that if we can increase current figures by 40%, we could decrease alcohol-related morality rates by 13% in men and 9% in women. Thus, it is important to motivate both physicians and patients to participate in treatment in alcohol use disorder. Recent epidemiological data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) are currently challenging the notion of alcohol use disorder as a fixed entity. Among a cohort of 4422 subjects initially diagnosed as having alcohol dependency, only 25% of these could still be diagnosed as alcohol-dependent one year later. Among the others, 27% were in partial remission, 12% had risk use, 18% low risk use and 18% were abstinent. Stable remission rates were observed in 30% of these subjects at 5 years. This study also argues in favour of the newer dimensional approach elaborated in the DSM 5. One potentially interesting treatment option is oriented toward reducing alcohol intake. In a study by Rehm and Roerecke (2013), they modelled the impact of reduced consumption in a typical alcoholic patient who drinks 8 glasses of alcohol per day (92 g of pure alcohol). If he decreases his alcohol intake by just one glass per day (12 g of alcohol per day), his one-year mortality risk falls from 180/100,000 to 120/100,000; if he decreases his intake by two glasses per day (24 g), this risk falls to 95/100,000, roughly half his baseline risk. These observations have resulted in integrating reduced consumption as an option into the treatment guidelines of several national institutions such as the National Institute for Clinical Excellence (NICE, UK), European Medicines Agency, as well as the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Decreasing stigmatisation of alcohol use disorder through public service announcements, in addition to more flexible physician attitudes concerning personal alcohol intake objectives may be key in getting increased numbers of patients into treatment programmes. In one study in Great Britain, 50% of patients in treatment for alcohol use disorder would prefer an initial objective of reduced consumption. A recent addition to the pharmacotherapy arsenal is nalmefene, which has been recently released as a medication to aid in reducing alcohol consumption. It is a strong µ and δ opioid receptor antagonist and a partial κ opioid receptor agonist. Opioid receptor antagonism is associated with reduced reward in relation to alcohol use, thus helping patients in reducing their consumption. Patients are instructed to take one nalmefene tablet two hours prior to each drinking occasion. Nalmefene therapy is to be accompanied by a specific psychosocial programme called BRENDA. BRENDA consists of a biopsychosocial evaluation, restitution of the evaluation to the patient, an empathetic approach that responds to patient needs, offering direct advice and adjusting goals and treatment programmes as the patient makes progress. Nalmefene has been associated with decreased heavy drinking days in two clinical trials. Overall, the treatment is well tolerated; adverse effects are fairly mild and short-lived. In conclusion, an approach that integrates reduced alcohol consumption makes sense from both a public and personal standpoint. Medications such as nalmefene have shown efficacy in association with a biopsychosocial approach to help patients attain their personal objectives with respect to alcohol use.

[Family management of cannabis in adolescent]. / Le cannabis chez l'adolescent : prise en charge par les familles.

Cannabis is the most frequently used illegal drug in France. In 2007, the average age for a first use was 15.1 years. Most teenagers will limit their use to a few experiences or controlled use. However, for those who do become dependent, the lapse between the first use and dependence is brief (approximately 18 months) with an average of 28 months compared to tobacco (3-5 years) and alcohol (5-9 years). In light of this brief delay, it is crucial to quickly recognize adolescents who have problem cannabis use and to educate parents to warning signs and to teach them how to efficiently discuss the subject with their teenager. Multidimensional Family Therapy, Cognitive and Behavioral Family Therapy and Brief Strategic Family Therapy have shown their efficacy in clinical trials. Improving family dynamics represents not only a motivational opportunity to help the adolescent to adhere to drug dependence treatment, but may also facilitate reintegration into a drug-free social environment and maintenance in a drug-free existence. Family interventions have been shown to be even more effective when community family assistance relations (social workers, educational counselors) are optimized. Family therapy should also be combined with personal empowerment and life planning interventions which enable the adolescent to increase his self-esteem through scholastic and professional achievement.

Mechanical interaction between cells and fluid for bone tissue engineering scaffold: modulation of the interfacial shear stress.

An analytical model of the fluid/cell mechanical interaction was developed. The interfacial shear stress, due to the coupling between the fluid and the cell deformation, was characterized by a new dimensionless number N(fs). For N(fs) above a critical value, the fluid/cell interaction had a damping effect on the interfacial shear stress. Conversely, for N(fs) below this critical value, interfacial shear stress was amplified. As illustration, the role of the dynamic fluid/cell mechanical coupling was studied in a specific biological situation involving cells seeded in a bone scaffold. For the particular bone scaffold chosen, the dimensionless number N(fs) was higher than the critical value. In this case, the dynamic shear stress at the fluid/cell interface is damped for increasing excitation frequency. Interestingly, this damping effect is correlated to the pore diameter of the scaffold, furnishing thus target values in the design of the scaffold. Correspondingly, an efficient cell stimulation might be achieved with a scaffold of pore size larger than 300 microm as no dynamic damping effect is likely to take place. The analytical model proposed in this study, while being a simplification of a fluid/cell mechanical interaction, brings complementary insights to numerical studies by analyzing the effect of different physical parameters.

Targeted mechanical properties for optimal fluid motion inside artificial bone substitutes.

Our goal was to develop a method to identify the optimal elastic modulus, Poisson's ratio, porosity, and permeability values for a mechanically stressed bone substitute. We hypothesized that a porous bone substitute that favors the transport of nutriments, wastes, biochemical signals, and cells, while keeping the fluid-induced shear stress within a range that stimulates osteoblasts, would likely promote osteointegration. Two optimization criteria were used: (i) the fluid volume exchange between the artificial bone substitute and its environment must be maximal and (ii) the fluid-induced shear stress must be between 0.03 and 3 Pa. Biot's poroelastic theory was used to compute the fluid motion due to mechanical stresses. The impact of the elastic modulus, Poisson's ratio, porosity, and permeability on the fluid motion were determined in general and for three different bone substitute sizes used in high tibial osteotomy. We found that fluid motion was optimized in two independent steps. First, fluid transport was maximized by minimizing the elastic modulus, Poisson's ratio, and porosity. Second, the fluid-induced shear stress could be adjusted by tuning the bone substitute permeability so that it stayed within the favorable range of 0.03 to 3 Pa. Such method provides clear guidelines to bone substitute developers and to orthopedic surgeons for using bone substitute materials according to their mechanical environment.

Ecological momentary assessment in addiction.

Numerous symptoms in psychiatry are subjective (e.g., sadness, anxiety, craving or fatigue), fluctuate and are environment dependent. Accurate measurement of these phenomena requires repeated measures, and ideally needs to be performed in the patient's natural environment rather than in an artificial laboratory environment or a protected hospital environment. The usual paper and pencil questionnaires do not meet these two conditions for reasons of logistics. A recently developed method, ecological momentary assessment (EMA), made it possible to implement these field assessments via ingenious use of various devices (most frequently an electronic diary) coupling an auditory signal with computerized data capture. The subject carries the device with him/her at all times, and data is recorded in vivo in real time. The programming of repeated measures in the form of a Likert scale or pull-down menu is easily achieved. A recall alarm system can help increase compliance. Compared with classical self-report, EMA improves the validity of the assessment of certain symptoms, which are the main evaluation criteria in clinical trials concerning certain pathologies (e.g., craving and treatment of addiction), where measurement was previously liable to bias. This article sets out to present this method, its advantages and disadvantages, and the interest it presents in psychiatry, in particular via three original applications developed by the authors including: measurement of reaction time without the knowledge of the subject in order to test certain cognitive models; use of a graphic solution for the data recorded for functional analysis of disorders; and the use of data collection via mobile phone and text messages, which also enables therapeutic interventions in real time by text messages, personalized on the basis of the situational data collected (e.g., in the case of craving, the associated mood, solitary or group consumption or concomitant occupations).

How plate positioning impacts the biomechanics of the open wedge tibial osteotomy; a finite element analysis.

A numerical model of the medial open wedge tibial osteotomy based on the finite element method was developed. Two plate positions were tested numerically. In a configuration, (a), the plate was fixed in a medial position and (b) in an anteromedial position. The simulation took into account soft tissues preload, muscular tonus and maximal gait load.The maximal stresses observed in the four structural elements (bone, plate, wedge, screws) of an osteotomy with plate in medial position were substantially higher (1.13-2.8 times more) than those observed in osteotomy with an anteromedial plate configuration. An important increase (1.71 times more) of the relative micromotions between the wedge and the bone was also observed. In order to avoid formation of fibrous tissue at the bone wedge interface, the osteotomy should be loaded under 18.8% (approximately 50 kg) of the normal gait load until the osteotomy interfaces union is achieved.

Emergency interruption of the inferior vena cava: a debatable issue.

In spite of improvements in the diagnosis and treatment of thromboembolic disease, pulmonary embolism continues to be a major cause of morbidity and mortality. Anticoagulation remains the preferred therapy for deep venous thrombosis; however, this form of treatment is either ineffective or contraindicated for some patients. For these patients, partial interruption of the inferior vena cava via percutaneous filter placement has become the procedure of choice to protect against fatal pulmonary embolism. We described in this paper results obtained with the available permanent filters and complications of these filters described in the literature. We highlighted the interest of temporary filters in patients whose thromboembolic risk is temporary, finally we insist on recognised indications for vena cava filters when anticoagulation is contraindicated or ineffective.

Early carotid endarterectomy after a nondisabling stroke: a prospective study.

On the recommendation of several studies, carotid endarterectomy (CEA) should be delayed for at least 6 weeks in patients suffering an acute nondisabling stroke. Our objective was to determine if these patients could be safely operated on earlier, thus decreasing the risk of a recurrent stroke prior to surgery. This prospective study, carried out from January 1990 to December 1997, included 72 consecutive patients having a nondisabling hemispheric stroke with severe ipsilateral carotid stenosis (NASCET 70-99%). All patients underwent CEA within 15 days of stroke onset. Patients were considered to have a nondisabling hemispheric stroke if (1) symptoms of hemispheric ischemia persisted longer than 24 hr and (2) the resulting deficit caused no major impairment in their everyday activities. All patients were examined by a neurologist prior to carotid angiography and contrast CT scan. Hemorrhage seen on the initial CT scan eliminated the patient from the study. If the CT scan with contrast injection was negative, patients underwent magnetic resonance imaging. CEA was performed under general anesthesia with intraluminal shunting. All patients had a postoperative duplex scan and yearly follow-up by a neurologist and a surgeon, with a duplex scan of the carotid arteries. Mean follow-up was 53 months. Our study shows that CEA can be performed relatively safely within 15 days following an acute nondisabling stroke. The arbitrary 6-week delay for CEA may unnecessarily expose patients with high-grade stenosis to a recurrent stroke, which could be prevented by earlier surgery.