[The role of an interventional pulmonologist in the management of metastatic pleural effusions (MPE)]. / Place du pneumologue interventionnel dans la gestion des pleurésies métastatiques.

An interventional pulmonologist possesses expertise in minimally invasive diagnostic and therapeutic procedures involving the airways, lungs and pleura. A malignant pleural effusion (MPE), which occurs in 20% of cancer patients, can be a daunting diagnostic challenge insofar as the pleural cavity is a closed cavity. In these patients, treatment may consequently be delayed before a precise diagnosis can be given. In the meantime, an interventional pulmonologist is called upon to carry out a wide range of examinations in order to establish the etiological diagnosis and to treat the symptoms of an MPE patient. Classical medical thoracoscopy, also called "pleuroscopy", is the reference method in MPE diagnosis because it allows visualization of the pleural cavity, pleural biopsy under direct visual control, providing excellent diagnostic yield. Over the past decade, new diagnostic methods have emerged, such as ultrasound-guided biopsy, as well as different interventions, such as indwelling pleural catheters, aimed at improving the quality of life of MPE patients, for whom therapeutic options are limited. The objective of this review of the literature is to point out the role of the interventional pulmonologist in the management of MPE by detailing the various diagnostic and therapeutic methods he possesses at the present time.

[Therapeutic education: A lever to change perceptions of bipolar disorder in family caregivers]. / L'éducation thérapeutique : un levier pour modifier les perceptions du trouble bipolaire chez les aidants familiaux.

OBJECTIVES: The patient with bipolar disorder and his family are caught in a reciprocal interaction: on one hand, the pathology leads to family sufferings and on the other hand, family behavior affects the disease of the patient and its development. Therefore, it seems of core importance that the psychologist should work with the family on their perception of bipolar disorder, that is to say, on their knowledge and psychological representations of the pathology. The aim of our study is to assess whether the initial perception of bipolar disorder evolves after a therapeutic education program. METHOD: Our research was conducted at the Bipolar Expertise Centre in Bordeaux/Centre Expert Bipolaire in Bordeaux on a sample of 145 participants (78patients and 67 family caregivers). They were all interviewed before and after the therapeutic education program (12 sessions in 6months). The Brief Illness Perception Questionnaire Revised (Moss-Morris, 2002) measures the perception of bipolar disorder and the BP Quizz (Fondation Fondamental) assesses the degree of knowledge of the disorder. RESULTS: Results show that therapeutic education helps families to level up their knowledge about bipolar disorder. Furthermore, representations on bipolar disorder have globally changed so that on average, bipolar disorder is viewed as less threatening by families after 12 sessions of therapeutic education. More precisely, after the program, families have a better understanding and a better insight of the disorder, which is then perceived as being less severe. On the emotional level, anxiety and stress have decreased. So there are an increase of knowledge and a change in perception. CONCLUSION: Our study shows that the therapeutic education program enables families to change their perception of the disease, that is to say, their knowledge but also their representations of the disease, which is a fundamental element according to the models of therapeutic education. Our results point out one of the active processes of therapeutic education at work in the sessions: in the perception of the disease, which is composed of both knowledge and representations of the disease, just a change in representations constitutes a lever for therapeutic education. Therefore, working on representations should be a therapeutic target. As a conclusion, we can say that therapeutic education of families cannot be reduced to an educational dimension which would only consist of gaining knowledge. Then, the right posture of the psychologist is to hold each participant's own development and changing process of representations.

Physical and mental health burden in cases of bipolar disorder classified as current, former, or non-tobacco smokers.

BACKGROUND: Tobacco smoking increases the global burden of bipolar disorder (BD). We examined markers of physical and mental health that are associated with tobacco smoking, controlling for confounders that have not always been considered in previous studies of BD. METHODS: Over 600 individuals with BD I or II referred to the French Network for bipolar disorder (FACE-BD) who completed standardized assessments, and could be reliably classified as current (CS) or former smokers (FS), were compared with those who were never smokers (NS) on: BD symptom load and psychiatric comorbidities; prevalence of alcohol and substance use disorders (ASUD); medication usage; functioning and physical health parameters. The bivariate and multivariate analyses took into account age and gender. RESULTS: 300 cases (49%) were CS, 78 (13%) FS and 238 (39%) had never smoked. Rates were similar across genders regardless of BD subtype. Compared with NS, CS were more likely to have an ASUD (Odds Ratio (OR) 5.18), BD I (OR 2.09), and lower abdominal obesity (OR 0.97), and FS were more likely to have an ASUD (OR 6.32) and higher abdominal obesity (OR 1.03). LIMITATIONS: The sample comprised of white Europeans; the FS subgroup was relatively small and we did not apply any statistical correction for the bivariate analyses. CONCLUSIONS: The increased risk of physical and mental health burden in CS and FS compared to NS represents avoidable morbidity in BD. This study offers support to the argument that individuals with BD should be routinely offered support to prevent or stop tobacco smoking.

Affect intensity measure in bipolar disorders: a multidimensional approach.

BACKGROUND: Emotional dysregulation, characterized by high levels of both arousal and intensity of emotional responses, is a core feature of bipolar disorders (BDs). In non-clinical populations, the 40-item Affect Intensity Measure (AIM) can be used to assess the different dimensions of emotional reactivity. METHODS: We analyzed the factor structure of the AIM in a sample of 310 euthymic patients with BD using Principal Component Analysis and examined associations between AIM sub-scale scores and demographic and illness characteristics. RESULTS: The French translation of the AIM demonstrated good reliability. A four-factor solution similar to that reported in non-clinical samples (Positive Affectivity, Unpeacefulness [lack of Serenity], Negative Reactivity, Negative Intensity), explained 47% of the total variance. Age and gender were associated with Unpeacefulness and Negative reactivity respectively. 'Unpeacefulness' was also positively associated with psychotic symptoms at onset (p=0.0006), but negatively associated with co-morbid substance misuse (p=0.008). Negative Intensity was positively associated with social phobia (p=0.0005). LIMITATIONS: We cannot definitively exclude a lack of statistical power to classify all AIM items. Euthymia was carefully defined, but a degree of 'contamination' of the self-reported levels of emotion reactivity may occur because of subsyndromal BD symptoms. It was not feasible to control for the possible impact of on-going treatments. CONCLUSIONS: The AIM scale appears to be a useful measure of emotional reactivity and intensity in a clinical sample of patients with BD, suggesting it can be used in addition to other markers of BD characteristics and sub-types.

[Prescription practices of antipsychotic medication in early psychosis: a two-year follow-up survey of subjects admitted in two psychiatric hospitals of South-Western France]. / Pratiques de prescription des traitements antipsychotiques dans les premières hospitalisations pour épisode psychotique: étude sur une cohorte de patients hospitalisés dans deux hôpitaux girondins.

OBJECTIVES: The aims of this pharmacoepidemiological study were to describe the antipsychotic medication received during the first admission and over a two-year follow-up in subjects with a first episode of psychosis, and to assess whether the prescriptions in naturalistic conditions were in adequacy with guidelines. METHOD: All first-admitted patients, less than 50 years old, consecutively hospitalised in 10 acute wards of two psychiatric hospitals serving Bordeaux's catchment area were included over a period of one year, if they presented with at least one overt psychotic symptom during the last month. Information on psychotropic medication received during the first admission was collected in medical records, and that received after the first admission was collected at the end of a two-year follow-up using multiple sources of information. RESULTS: Of the 86 patients included in the cohort, 53 presented with broadly defined schizophrenia and 33 with psychotic mood disorder. All except two subjects were prescribed at least one neuroleptic drug. Antipsychotic drugs (amisulpride, olanzapine, risperidone, clozapine) were the most frequently prescribed drugs during the first admission and over the two-year follow-up. If sedative neuroleptics were excluded, antipsychotic drugs were the first prescribed neuroleptic drugs in a large proportion (80%) of patients. Although few patients were first prescribed a conventional neuroleptic, the proportion of subjects treated with these drugs increased over the next prescriptions, and one out of three patients was prescribed at least one of these drugs during the follow-up. The mean dose of antipsychotic drugs at first discharge was higher than that recommended in first episode patients (amisulpride 616 mg, olanzapine 13 mg, risperidone 7 mg). Coprescription of neuroleptic drugs, found in one third of patients at all times of assessment, was especially due to coprescription of a sedative neuroleptic to a conventional or an antipsychotic one. Nearly half of the patients did not take any psychotropic medication at the end of the follow-up. CONCLUSION: The main recommendation specifying that the first neuroleptic treatment in subjects with a first episode of psychosis should use antipsychotic drugs instead of conventional neuroleptics was generally respected in this cohort of first-admitted subjects with psychosis. However, conventional neuroleptics were found in first or second rank prescriptions, although they should not be used before at least the third rank. The recommendations that the initial neuroleptic dose should be lower in subjects with a first episode, and that coprescription of neuroleptics should be avoided, were frequently not respected. This study highlights the fact that international guidelines should be better applied in naturalistic conditions, and that clinicians have to be better informed about these recommendations.

[Multiplicity of syndromes associating manic and depressive symptoms: the need for a dimensional approach]. / Multiplicité des syndromes associant symptômes dépressifs et maniaques: nécessité d'une approche dimensionnelle.

The heterogeneity of mood states in bipolar disorders leads to some confusion in diagnostic and therapeutic strategies. Apart from the classical syndromes characterizing euphoric mania and melancholic depression, recent literature has pointed to alternative mood states associating both manic and depressive symptoms. This resulted in the definition of various syndromes including mixed states, dysphoric mania, agitated depression and more recently the depressive mixed state. This consequently raises the question of the best therapeutic strategies. As the boundaries between the various states associating both depressive and manic symptoms have yet to be clarified, there is a need to further discuss whether dimensional rather than categorical approaches could help to further refine their definitions and define the best therapeutic strategies. As stated by Kraepelin, mood episodes in manic-depressive illness were defined according to three dimensions: mood, cognitive processes, and motor and motivational drive. Cognitive and motor processes were regarded as quantitative items whose alterations may correspond to either an increase or a decrease. The current definitions are far from this dimensional approach. Thus, the current diagnostic criteria make it difficult to define mixed states. Such poorly convincing diagnostic criteria may account for the description of many other states exhibiting both manic and depressive symptoms. A dimensional approach could be useful to define mood states in bipolar disorders. These dimensions should progressive, from inhibition to excitation. Because tonality affects is not a dimension, the emotional reactivity (hyper-reactivity versus hypo-reactivity) represents an additional dimension that would help characterize these states better.

Pattern of health service utilization and predictors of readmission after a first admission for psychosis: a 2-year follow-up study.

OBJECTIVE: To explore the pattern of health service utilization over 2 years following a first admission for psychosis and the baseline characteristics predicting readmission. METHOD: Patients included in a cohort of first-admitted subjects with psychosis (n = 84) were assessed at the end of a 2-year follow-up using multiple sources of information. RESULTS: At the end of the follow-up, one of three subjects had no contact with any mental health professional, and 38% of subjects had no contact with a psychiatrist. Half of the patients were readmitted over the 2-year follow-up. The baseline characteristics independently predicting psychiatric readmission were a high number of helping contacts before first admission and persistence of psychotic symptoms at discharge. CONCLUSION: Decreasing the frequency of readmission in the early course of psychosis is a public health priority. Development of psychotherapeutic programs for subjects with early psychosis who have enduring psychotic symptoms at first discharge should be promoted.

Pathways to care of first-admitted subjects with psychosis in South-Western France.

BACKGROUND: A limited number of studies have assessed the pathways to care of patients with first-episode psychosis. The aim of the study was to describe the pathways to care of subjects with psychosis between onset of psychosis and first admission, and to examine the demographic and clinical factors influencing access to care. METHOD: Number and type of helping contacts since onset of first psychotic symptoms were assessed using multiple sources of information in 86 subjects with psychosis first-admitted in two hospitals of South-Western France. Characteristics independently associated with long delays between onset of symptoms and first helping contact, first treatment and first admission were explored using logistic regressions. RESULTS: Twelve per cent of subjects were first admitted without any previous helping contact. The patients were seen by a median of two helpers (maximum 7). For most patients (70%), the first helping contact was a health care professional, and the same proportion of patients had a first contact with a GP or a psychiatrist. The type of first contact was not predicted by demographic or clinical characteristics. Subjects with poor pre-morbid functioning or at-risk behaviour were more likely to have a delayed access to care. CONCLUSIONS: The delay in access to care may not be totally attributed to inadequate management by health professionals, but may be a characteristic of the disease itself, at least in part independent of the organization of the health system.

Optimization of the index profile of an optical fiber at N wavelengths.

The paper provides simple expressions for the dopant concentrations that optimize the bandwidth of a fiber at a number of wavelengths. The solution is related to Olshansky's multiple alpha profiles. Numerical application is made for germania, fluor, and phosphorus doping at wavelengths where the losses are small. The effect of a free parameter on the fiber Delta and its bandwidth is outlined.