[Paranoid personality disorder and criminal offense]. / Trouble de personnalité paranoïaque et infractions pénales.

BACKGROUND: Currently, all of the studies that focus on the relationship between paranoia and criminal offenses exclusively concern subjects suffering from a delusional paranoid disorder. However, subjects with single paranoid personality disorder, without any associated delusional disorder, are not uncommon in forensic practice. OBJECTIVES: This study aims to describe the offenses committed by subjects suffering from a single paranoid personality disorder and to compare them with the offenses committed by the subjects affected by a paranoid delusional disorder associated with paranoid personality disorder. Our initial hypothesis is that both populations have a comparable criminological profile. METHODS: Based on a 17 year-long experience carried out in the framework of a forensic assessment, we have selected all subjects presenting a paranoid personality disorder, whether single or associated with paranoid delusional disorder. The selected individuals were divided into two groups according to whether they presented paranoid delusional disorder or not. The offenses were grouped into criminal categories. The alpha risk was fixed at 1%. Data analysis is done by SAS software version 9.4. RESULTS: In a sample of 106 subjects presenting a paranoid personality disorder, including 4 women and 102 men, we found 79 subjects with a single paranoid personality and 27 with an associated paranoid delusional disorder. The average age at the time of the offense was 41 for those with single personality disorders and 49 for those with paranoid delusional disorders. Both groups had forensic antecedents (41%, 11/27 of paranoid delusional disorder and 51%, 40/79 of single paranoid personality disorder). Psychiatric history was more frequent in the paranoid delusional disorder group (59%, 16/27) than in the single paranoid personality disorder group (13%, 10/79). History of addiction was comparable in terms of alcohol abuse (26% in both groups) and other substances (7.5%, 2/27 of paranoid delusional disorder and 9%, 7/79 of single paranoid personality disorder). Comparison of the two groups highlighted significant differences in the type of criminal offenses committed (Fisher's exact test: P=0.0003, alpha risk <0.0001). The offenses committed by delusional authors essentially came down to verbal or physical violence, including homicide (44%, 12/27), and were usually focused on a designated persecutor. Sexual violence was rare. On the other hand, paranoid personality disorder was associated with a wider variety of offenses. Sexual offenses (including 28 rapes, 35%, 28/79) were thus almost as frequent as murder, and attempted murder (38%, 30/79). This diversity of committed offenses was found in their forensic antecedents. In these subjects, the logic of omnipotence may had over ruled the logic of revenge. CONCLUSION: We conducted a retrospective study on 106 subjects with paranoid personality disorder, including 27 subjects with associated paranoid delusional disorder. The comparison of the two groups demonstrated significant differences in offenses. Verbal and physical but non-sexual violence, committed in a delusional logic, was found among delusional subjects, while the forms of violence were more multiform in the single paranoid personality disorder group, frequently including sexual violence. This is, as far as we know, the first study describing the medico-legal acting-out of paranoid personalities. These results, which will need to be confirmed by future studies, point out the importance of the criminological risk that may be associated with paranoid personality disorder, without any associated delusional disorder.

Detection of circulating Aspergillus fumigatus DNA by real-time PCR assay of large serum volumes improves early diagnosis of invasive aspergillosis in high-risk adult patients under hematologic surveillance.

Detection of galactomannan antigen (GMA) in serum is the standard assay for the diagnosis of invasive aspergillosis (IA) in high-risk patients with hematological disorders. Detection of Aspergillus DNA in serum has been proposed, but its sensitivity is lower than that of GMA when small serum volumes (SSV) are used. In this study, we investigated whether extraction of DNA from large serum volumes (LSV) improves diagnostic yield. In a 13-month prospective study, we compared the performances of twice-weekly screening of serum for GMA by an enzyme immunoassay and weekly screening for Aspergillus fumigatus DNA by a real-time PCR (RT-PCR) assay of 1.0 ml (LSV) or 100 mul (SSV) of serum. We included 124 patients (138 treatment episodes), with 17 episodes of EORTC (European Organization for Research and Treatment of Cancer)/MSG (Mycoses Study Group)-documented IA. In all, 1,870 samples were screened for GMA. The sensitivity (Se), specificity (Sp), and positive and negative predictive values (PPV and NPV, respectively) of GMA for IA were 88.2%, 95.8%, 75%, and 98.3%, respectively. We screened 938 samples for Aspergillus DNA by using LSV; 404 of these samples were also tested with SSV. The Se, Sp, PPV, and NPV of RT-PCR were 100%, 96.7%, 81%, and 100%, respectively, with LSV and 76.5%, 96.7%, 81.3%, and 95.6%, respectively, with SSV. DNA detection gave a positive result when performed on LSV in two cases of IA where the GMA assay result remained negative. Furthermore, in four IA cases, DNA was detected earlier than GMA. The use of LSV for extraction improved the performance of the RT-PCR, which appears highly sensitive and specific for the early diagnosis of IA in high-risk patients with hematological disorders.

Oestrogen withdrawal associated psychoses.

OBJECTIVE: Oestrogen withdrawal has been hypothesized as playing a causal role in puerperal psychoses. However, oestrogen withdrawal exists in conditions others than puerperium. We searched the published case reports where a decrease in oestrogen levels not occurring during puerperium was associated with a psychotic disorder, in order to evaluate the relevance of this hypothesis. These cases were defined as oestrogen withdrawal associated psychoses. METHOD: A systematic research of the literature was conducted for the period 1960-2000. RESULTS: We identified 26 observations reporting an association between a psychotic disorder and a phase of oestrogen withdrawal. Psychotic episodes were short and reversible with recurrences reported when oestrogen withdrawal recurred. Puerperal psychosis was frequently reported in the history of patients. CONCLUSION: The oestrogen withdrawal hypothesis can be extended to certain psychotic episodes not occurring during in puerperium. This provides an additional argument for the clinical relevance of oestrogen withdrawal in puerperal and related psychoses.

Long-term pharmacological treatment of generalized anxiety disorder.

Generalized anxiety disorder (GAD) is one of the most common anxiety disorders and has a poor prognosis, although it is often thought to be a minor complaint. This disorder has a chronic course of 5-15 years and longer. Long-term treatment with the commonly used benzodiazepines is controversial because of concerns over tolerance and dependence. We performed a thorough search of the literature for clinical trials of a duration of over 2 months conducted in patients with generalized anxiety disorder in order to identify any successful long-term treatment of this disorder. Only eight long-term reports of studies conducted in well-defined homogeneous groups of patients diagnosed with generalized anxiety disorder were found with the methodology of these studies presenting a number of limiting factors. The results are inconclusive and no reference drug could be identified. In addition, an adequate evaluation of the long-term treatment of GAD has not yet been performed.

Low plasma concentrations achieved with conventional schedules of administration of ganciclovir in patients with AIDS.

Plasma concentration of ganciclovir was studied prospectively in 15 AIDS patients treated for acute cytomegalovirus (CMV) retinitis. Ganciclovir was administered at a mean dose of 10.3 +/- 0.6 mg/kg/day. The mean trough plasma concentration was 0.6 +/- 0.3 mg/L (n = 24), and the mean peak concentration was 7.2 +/- 2.4 mg/L (n = 6). In 12 patients, trough concentrations were below the range that has been associated with effective treatment. Low trough concentrations were associated with treatment failure in 6 patients. Following an increase in the daily dose, improvement was observed in 4 of the 6 patients. These results suggest that low plasma ganciclovir levels are associated with the failure of therapy. Monitoring the plasma concentration of ganciclovir may thus be useful before considering the virus to be resistant to the drug or before switching from ganciclovir to foscarnet.

[Mania in an elderly subject: I. -- manic-depressive disorders of late onset]. / La manie du sujet âgé: I--Les maladies maniaco-dépressives à début tardif.

Late mania may inaugurate a late-onset bipolar illness. Atypical features and organic brain abnormalities are frequently associated. Late-onset bipolar illness is apparently characterized by a strong instability of mood and a super or subsensitivity to neuroleptics and antidepressant drugs. However, there is a strong efficacy of lithium salts and lithium may be used as a curative and preventive treatment or as a therapeutic test, especially in atypical cases. The occurrence of mania in elderly people involves a specifical etiologic, therapeutic and diagnostic approach.

[Mania in an elderly subject: II. -- the evolution of manic-depressive disease]. / La manie du sujet âgé: II--Evolution de la maladie maniaco-dépressive.

The occurrence of mania in the elderly is under-estimated. Mania may inaugurate a late-onset bipolar illness, extend a unipolar depressive disorder or rarely continue a early-onset bipolar illness. Early-onset bipolar illness frequently disappear after 60 years or is prolonged by reccurrent depression. Late-onset bipolar illness may be preceded by slight disturbances of mood. These modalities underline two of the various evolutions of bipolar illness. Only a prospective follow-up study could specify it.

[Role of biological clock in human pathology]. / Rôle de l'horloge biologique en pathologie humaine.

Most of the vegetative, hormonal and behavioural functions of the human organism operate under the biological control of a circadian clock which responds to environmental and social stimuli, synchronizing the organism's physiology to daily and seasonal rhythms. The underlying anatomic structures are located in the suprachiasmatic nucleus and the pineal gland. Although the precise physiologic mechanisms involved are still under study, melatonin is known to play a major role. Normal function of the circadian clock is disrupted in jet-lag, night-shift work, and blindness as well as in rare cases of lesions to the pineal gland leading to a shift in biological rhythms including hormone secretion and control of body temperature, for example. Several signs of impaired function have been identified: various types of sleep disorders, memory and concentration impairment, dysphoria, asthenia, irritability. Seasonal recurrence of such signs and frequent depressive complications are also suggestive of a disorder in the circadian clock. Knowledge of specific clinical signs and biological parameters will undoubtedly lead to the discovery of other disease states dependant on the circadian clock and to the development of therapeutic strategies capable of regulating the organism's chronobiology.

Neurosteroids, via sigma receptors, modulate the [3H]norepinephrine release evoked by N-methyl-D-aspartate in the rat hippocampus.

N-Methyl-D-aspartate (NMDA, 200 microM) evokes the release of [3H]norepinephrine ([3H]NE) from preloaded hippocampal slices. This effect is potentiated by dehydroepiandrosterone sulfate (DHEA S), whereas it is inhibited by pregnenolone sulfate (PREG S) and the high-affinity sigma inverse agonist 1,3-di(2-tolyl)guanidine, at concentrations of > or = 100 nM. Neither 3 alpha-hydroxy-5 alpha-pregnan-20-one nor its sulfate ester modified NMDA-evoked [3H]NE overflow. The sigma antagonists haloperidol and 1-[2-(3,4-dichlorophenyl)-ethyl]-4-methylpiperazine, although inactive by themselves, completely prevented the effects of DHEA S, PREG S, and 1,3-di(2-tolyl)guanidine on NMDA-evoked [3H]NE release. Progesterone (100 nM) mimicked the antagonistic effect of haloperidol and 1-[2-(3,4-dichlorophenyl)ethyl]-4-methyl-piperazine. These results indicate that the tested steroid sulfate esters differentially affected the NMDA response in vitro and suggest that DHEA S acts as a sigma agonist, that PREG S acts as a sigma inverse agonist, and that progesterone may act as a sigma antagonist. Pertussis toxin, which inactivates the Gi/o types of guanine nucleotide-binding protein (Gi/o protein) function, suppresses both effects of DHEA S and PREG S. Since sigma 1 but not sigma 2 receptors are coupled to Gi/o proteins, the present results suggest that DHEA S and PREG S control the NMDA response via sigma 1 receptors.

[Infections related to external ventricular drainage]. / Infections sur matériel de dérivation ventriculaire externe.

Infection is the main complication of external ventricular drainage (EVD). This retrospective study assessed the relationships between EVD duration, antibiotics and cerebrospinal fluid (CSF) infection. From January 1990 to December 1991, 53 neurosurgical patients, aged 7-76 years, a simplified acute physiological score (SAPS) of 1-20 and having a total of 64 EVD, were included in this study. CSF withdrawn from the drain was collected daily for bacteriological, biochemical and cytological analysis, until the EVD removal. CSF colonization was defined by a positive direct examination or a positive culture of CSF, in the absence of biochemical and cytological abnormalities. CSF drain infection was defined by a low glucose concentration or leucocytosis without blood contamination. However the results of bacteriological analysis were modified by the antibiotics. The group of non infected patients and the group of those with an infected or a colonized drain were comparable with regard to underlying neurosurgical diseases, age, SAPS, Glasgow coma scale and delay between hospital admission and day of drain insertion and antibiotic administration. The EVD duration was significantly longer in infected EVD and colonized EVD. Staphylococci were the most frequently recognized bacteria and coagulase-negative staphylococci predominated in CSF of colonized EVD. In five patients, antibiotics were unable to cure a meningitis. Their leucocyte count was increased. The glucose concentration was low, but the culture, remained negative. It is concluded that duration and rate of EVD influence more the incidence of infections than the systemic administration of antibiotics.

[Massive pulmonary embolism caused by thrombosis formed on a central catheter in a child]. / Embolie pulmonaire massive due à une thrombose sur cathéter central chez un enfant.

A case is reported of a 9-year-old girl admitted with a subarachnoid haemorrhage. Her neurological recovery was favourable after the embolization of a cerebral arterio-venous malformation. She stayed in ICU with mechanical ventilation because of a bacterial pneumonia and a post-extubation laryngeal oedema. She required insertion of a polyurethane subclavian catheter, as a peripheral venous access was not available. Five days later, the child suffered a sudden respiratory distress without changes of the electrocardiogram and the chest X-ray. The diagnosis of pulmonary embolism was suspected because of the presence of the central venous catheter, a catheter dysfunction and a superior vena cava syndrome. A catheter tip thrombus was shown by angiography as well as a thrombus in the pulmonary artery, a 90% obstruction of the proximal valvular tree of the right lung, a 10 to 15% distal obstruction in the left lung, a complete obstruction of the superior vena cava (SCV). The thrombolytic therapy was contra-indicated in this case because of the neurological pathology. Heparin was given by continuous intravenous infusion. When heparin concentration was at an appropriate level, the catheter was removed. Its microbiological culture remained negative. The next day, another angiography showed a partial permeability of the SVC and a better right pulmonary perfusion. During this procedure, the haemodynamic assessment showed only moderate abnormalities. Therefore the surgical treatment was not indicated and the heparin continued. The child recovered gradually with a normalization of the lung scintigraphy.

Effects of age on plasma protein binding of sufentanil.

The plasma protein binding of sufentanil has been studied in newborns, infants (0.5 +/- 0.3 yr), children (6.8 +/- 3.0 yr), and adults (39.5 +/- 9.0 yr). Binding of sufentanil was determined in vitro by equilibrium dialysis, and radioactive tritiated sufentanil was used for the determination of drug concentrations in plasma and buffer. The free fraction of sufentanil was significantly higher in the newborn (19.5 +/- 2.7%; P less than 0.01) than in the other age groups. The free fraction was also significantly higher in infants (11.5 +/- 3.2%; P less than 0.01) than in children (8.1 +/- 1.4%) or in adults (7.8 +/- 1.5%) but did not differ significantly between children and adults. The free fraction of sufentanil was strongly correlated with the alpha 1-acid glycoprotein plasma concentration (r = -0.73; P less than 0.001) whereas it was weakly correlated with albumin plasma concentration (r = -0.35; P less than 0.05). These data suggest that the lower concentration of alpha 1-acid glycoprotein in newborns and infants probably accounts for the decrease in protein binding of sufentanil in these age groups when compared with that in older children or adults. The increased free fraction in the neonate might contribute to the enhanced effects of lipophilic opioids in the neonate.