[Attention deficit disorder: multidisciplinary observational study over 1 year]. / Le trouble déficitaire de l'attention, avec ou sans hyperactivité (TDA/H) : une approche pluridisciplinaire longitudinale croisée de 36 enfants.

INTRODUCTION: In France, attention deficit disorder (ADHD) has traditionally met with two opposing approaches (biological and psychoanalytic). This conflict led us to conduct a multidisciplinary observational study, on a group of 36 children over a period of 1 year. METHODS: Thirty-six children with ADHD diagnostic (DSM IV), not treated by MPH were included. Initial "multi-field" evaluation (T0) consisted of: neuro-paediatric consultation (Conners questionnaire, Child Behaviour Checklist, reading and writing scores by French tests); semi-structured child psychiatric interview (DSM-IV axis I), structural hypothesis (CFTMEA), existence of narcissistic fragility, parents/child interactions; neuropsychological standardized evaluation (attention and executive functions); psychodynamic interview and projective tests (Rorscharch, CAT or TAT). A therapeutic project is proposed combining MPH and psychotherapy according to the results. A new evaluation 1 year later (T1) included a consultation and a neuropsychological evaluation. RESULTS T0: All parental questionnaires appreciating attention deficit and hyperactivity/impulsivity were significantly pathological. The neuropsychological evaluation showed usual characteristics of ADHD with individual differences. The psychiatric evaluation revealed the frequency of comorbidity in axis I (23% of children with more than two diagnoses, 57% with anxiety disorder, 23 and 3% with oppositional and conduct disorder). FOLLOW UP (T1): Thirty-one children were re-examined (20 treated by MPH and 11 not treated because of parental refusal or particular psychopathological situations). Psychoanalytical psychotherapy, proposed to 28 children, was undertaken with only 19. An improvement in scores for attention and executive tests was registered only in the treated group. DISCUSSION: The tests confirm deficits of attention and executive functions without correlation with the scores of questionnaires, underlining the need for a neuropsychological evaluation to objectify attention disorders. Projective tests refine and enrich psychiatric evaluation and showed that half of the children had borderline organization. However, structural hypotheses were heterogeneous, suggesting the need for specific therapeutic projects to be devised according to each child. The treated children were the only ones to improve attention deficit. On the other hand, the scores of anxiety are not improved by MPH, emphasizing the indications of psychotherapy if comorbidity is present. Psychotherapeutic care was carried out only among part of the population, because of parental reservations, exacerbated by differences of opinion among professionals and lack of access. CONCLUSION: This study is innovative, providing precise data on ADHD from a multidisciplinary perspective. Psychopathological comorbidity is high in this population, so the concept of ADHD cannot be limited to a cognitive point of view. These elements and doubts regarding the efficacy of behavioural therapies suggest the need for a rigorous evaluation of analytical psychotherapies independent of MPH to treat attention deficit.

Inter- and intraobserver variability in the interpretation of computed tomography of the lumbar spine.

In order to assess the variability in interpreting lumbar CT-scans, two radiologists and two rheumatologists examined the same set of 40 CT-scans and evaluated the presence of primary abnormalities using pre-established criteria. Inter- and intraobserver concordance was assessed using kappa statistics. Interpretation of herniated nucleus pulposus appeared reliable in this study (interobserver and intraobserver kappa statistics approximately 0.7 and 0.9, respectively). Conversely, significant variability of interpretation was seen in many findings often considered important in benign low-back pain or sciatica. Particularly low levels of agreement (interobserver kappa statistics lower to 0.20) were found for facet joint osteoarthritis and spinal stenosis. Since herniated nucleus pulposus appeared as the only reliable CT finding, lumbar CT ordering should therefore be currently restricted to confirmation and localization of herniated nucleus pulposus, especially when surgery or any other invasive intervention is planned to treat prolonged sciatica.

Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice.

OBJECTIVE: To describe the natural course of recent acute low back pain in terms of both morbidity (pain, disability) and absenteeism from work and to evaluate the prognostic factors for these outcomes. DESIGN: Inception cohort study. SETTING: Primary care. PATIENTS: 103 patients with acute localised non-specific back pain lasting less than 72 hours. MAIN OUTCOME MEASURES: Complete recovery (disappearance of both pain and disability) and return to work. RESULTS: 90% of patients recovered within two weeks and only two developed chronic low back pain. Only 49 of 100 patients for whom data were available had bed rest and 40% of 75 employed patients lost no time from work. Proportional hazards regression analysis showed that previous chronic episodes of low back pain, initial disability level, initial pain worse when standing, initial pain worse when lying, and compensation status were significantly associated with delayed episode recovery. These factors were also related to absenteeism from work. Absenteeism from work was also influenced by job satisfaction and gender. CONCLUSIONS: The recovery rate from acute low back pain was much higher than reported in other studies. Those studies, however, did not investigate groups of patients enrolled shortly after the onset of symptoms and often mixed acute low back pain patients with patients with exacerbations of chronic pain or sciatica. Several sociodemographic and clinical factors were of prognostic value in acute low back pain. Factors which influenced the outcome in terms of episode recovery (mainly physical severity factors) were only partly predictive of absenteeism from work. Time off work and return to work depended more on sociodemographic and job related influences.

Polymyalgia rheumatica and temporal arteritis: a retrospective analysis of prognostic features and different corticosteroid regimens (11 year survey of 210 patients).

The treatment of polymyalgia rheumatica (PMR) and temporal arteritis (TA) is still controversial. To assess the influence on the course of these diseases of the clinical symptoms at initial presentation and of the starting dosage of corticosteroid (CS) treatment the data for 210 patients, who were diagnosed as having PMR or TA from 1976 to 1986 and were followed up closely, were reviewed. One hundred and thirty two patients were diagnosed as having 'clinically pure' PMR; prednisone starting doses of over 15 mg daily provided more CS related adverse effects without any advantage. The mean duration of treatment was 25.7 months. Nine patients later developed symptoms of TA, and there were no predictive features for this. None experienced visual or neurological complications. Seventy eight patients were diagnosed as having clinical TA. Twenty five patients treated with low starting doses of prednisone, ranging from 10 to 20 mg/d (mean 16.2 mg/d), developed less CS related adverse effects and did not have more visual or neurological complications than 53 patients treated with higher doses. The mean duration of treatment was 30.9 months. Fifteen patients experienced visual or neurological complications and men (10/30) developed these complications more frequently than women (5/48) (p less than 0.02). These results suggest that (a) clinically pure PMR is a benign disease requiring low doses of CS treatment; (b) low doses of CS seem an adequate treatment for most cases of TA; (c) a worse prognosis seems attached to the male sex in TA.

[Osteoradionecrosis in adults]. / Les ostéoradionécroses de l'adulte.

Osteoradionecrosis (ORN) is not exceptional, despite advances in irradiation techniques. Six cases are reported, involving the pelvis, coxofemoral joint, mandible and vertebrae; in this last case, the semiologic value of the lucent intrasomatic image seen on plain films and tomographies of the vertebrae is underscored. The irradiation dose (above 3 000 rad) is the chief factor in osteoradionecrosis, which may be precipitated by adjuvant factors and potentiating events such as trauma and infection. Pathologic study shows several lesions whose association is suggestive: cell lesions, osteoporosis, vascular lesions, and foci of necrosis. The pathogenic significance of lesions of bone cells is demonstrated, while the part played by vascular lesions is controversial. Involvement of the pelvis and hips following irradiation of pelvic carcinoma is the most common. The scapular girdle and ribs may be involved in irradiation for breast cancer. In involvement of the mandible, remarkable features are its frequency following irradiation of carcinoma of the mouth, the significant part played by potentiating factors, i.e. infection and trauma, severity of complications, i.e. fistulae and hemorrhage, and lastly difficulties of management. Among infrequent sites, involvement of the vertebrae is of interest as it may mimic collapse due to osteoporosis or metastasis. Diagnosis rests on an association of criteria, and fortunately bone biopsy is usually unnecessary. The clinical features, topographical characteristics and course of the disease allow differentiation from bone metastasis; it may be more difficult to distinguish postirradiation sarcoma, which is exceptional, or a number of benign conditions, such as aseptic necrosis, infectious osteoarthritis, and destructive coxarthrosis.

[Association between mycosis fungoides and myasthenia gravis (author's transl)]. / Association mycosis fungoïde-myasthénie.

Myasthenia gravis characterized by physical examination, electrophysiologic abnormalities, ephedronium test, without thymoma, associated in a 47 year-old-man, with mycosis fungoides. Myasthenia gravis began two years after the onset of mycosis fungoides, and the patient died of infection four years after the development of the cutaneous lymphoma. At autopsy, there was no visceral involvement. Myasthenia gravis and lymphoma rarely coexist; the occurrence of myasthenia gravis shortly after the onset of mycosis fungoides suggests that the two disorders may be linked by immunological abnormalities.