Uma clínica em extensão: a psicanálise na atenção básica / Une clinique d'extension: la psychanalyse dans les soins primaires / An extension clinic: psychoanalysis in primary care

Nas últimas décadas, observamos que a psicanálise expandiu suas fronteiras para além dos seus espaços tradicionais, como em núcleos de ensino e pesquisa universitários e serviços e movimentos psiquiátricos e de saúde mental, dividindo-se em várias correntes e em diversas associações e escolas psicanalíticas. O percurso da disciplina psicanalítica nos mostra que vários desafios foram impostos à psicanálise, dentre estes a necessidade de problematizar os campos de intervenção possíveis. O psicanalista que atua no campo institucional, a partir do seu trabalho com pacientes e equipes de saúde, deve se responsabilizar pela transmissão do saber que ali se constrói, visto que essa clínica, ao ocorrer na instituição de saúde, produz efeitos tanto para a clínica quanto para a própria instituição. Portanto, este trabalho tem por objetivo apresentar, a partir das vinhetas clínicas, as intervenções possíveis do psicanalista junto às equipes de saúde da Atenção Básica sob a perspectiva do matriciamento

Au cours des dernières décennies, nous avons observé que la psychanalyse a élargi ses frontières au-delà de ses espaces traditionnels, comme dans les centres d'enseignement et de recherche universitaire et dans les services et mouvements psychiatriques et de santé mentale, se divisant en plusieurs courants et diverses associations et écoles psychanalytiques. Le parcours de la discipline psychanalytique nous montre que plusieurs défis se sont imposés à la psychanalyse,parmi lesquels la nécessité de problématiser les champs d'intervention possibles. Le psychanalyste qui travaille dans le champ institutionnel, à partir de son travail avec les patients et les équipes soignantes, doit avoir la responsabilité de transmettre les connaissances qui s'y construisent, puisque cette clinique, lorsqu'elle se déroule dans l'établissement de santé, produit des effets tant pour la clinique que pour ainsi que pour l'institution elle-même. Ce travail vise donc présenter, à partir de vignettes cliniques, les interventions possibles du psychanalyste auprès des équipes de soins de première ligne dans une perspective d'accompagnement matriciel

In recent decades, we have observed that psychoanalysis has expanded its borders beyond its traditional spaces, such as in university teaching and research centers and psychiatric and mental health services and movements, dividing into several currents and various psychoanalytic associations and schools. The path of the psychoanalytic discipline shows us that several challenges were imposed on psychoanalysis, among them the need to problematize the possible fields of intervention. The psychoanalyst who works in the institutional field, based on his work with patients and healthcare teams, must be responsible for transmitting the knowledge that is constructed there, since this clinic, when taking place in the healthcare institution, produces effects both for the clinic as well as for the institution itself. Therefore, this work aims to present, based on clinical vignettes, the psychoanalyst's possible interventions with Primary Care health teams from the perspective of matrix support.

Os impasses ao acesso à intersubjetividade: observações clínicas de um bebê com risco de evolução autística / Impases en el accesoa la intersubjetividad: observaciones clínicas de un bebé con riesgo de evolución autista / Challenge in accessing intersubjectivity: clinical observations of a baby with a risk of autism / Les impasses à l'accès à l'intersubjectivité: observations cliniques d'un bébé à risque d'autisme

O artigo aborda os impasses vividos por um bebê com risco de autismo em seu processo de subjetivação. Estudos afirmam que há bebês que, muito precocemente, recusam-se a estabelecer trocas com o objeto materno, impossibilitando que a mãe entre em um estado de identificação com seu bebê, o que colocaria em pauta que o autismo infantil não se limitaria apenas a uma falha materna, mas se trataria de uma patologia multifatorial. Quais intervenções clínicas seriam necessárias para que a mãe e o bebê possam juntos (re)escrever uma nova narrativa psíquica? Haveria um tipo de intervenção e de manejo clínico específico nos casos de bebês com risco de autismo? E como a psicanálise contemporânea, fundamentada pela leitura da intersubjetividade, nos ajudaria na compreensão da clínica da intervenção precoce?

Este artículo se propone abordar los impases experimentados por un bebé con riesgo autista en su proceso de subjetivación. Existen estudios sobre bebés que precozmente se niegan a establecer intercambios con el objeto materno, imposibilitando que la madre entre en identificación con él, poniendo sobre la mesa que el autismo infantil no se limitaría a una falla materna, sino que se trataría de una patología multifactorial. Se plantea, cuáles intervenciones clínicas son necesarias para que madre y bebé puedan (re)escribir una nueva narrativa psíquica, que posibilite un verdadero encuentro diádico. ¿Habría un tipo específico de intervención y manejo clínico en los bebés con riesgo de autismo? ¿Cómo el psicoanálisis contemporáneo, basado en la lectura de la intersubjetividad y de lo intrapsíquico, ayudaría a entender la clínica de la intervención precoz?

This article addresses the failures of a baby with a risk of autism to develop his subjectivation process. Recent studies show that some babies are not able to develop exchanges with their maternal object, which would show that children autism would not be limited to a failure of the mother to enter into a state of identification with her baby, but would be associated to a multifactorial pathology. In that respect, which clinical interventions would be necessary so that mother and baby can (re)write a new psychic narrative, enabling them to develop a genuine capability to meet together? Is there a type of clinical handling for babies with a risk of autism? How can contemporary psychoanalysis, with focus on intersubjectivity and inter-psychism, could help us to understand early intervention clinic?

Cet article aborde les entraves d'un bébé à risque autistique à développer son processus de subjectivation. Des études récentes montrent que certains bébés ne sont pas capables de développer des échanges avec leur objet maternel, ce qui montrerait que l'autisme infantile ne se limiterait pas seulement à un échec de la mère d'entrer dans un état d'identification avec son bébé, mais qu'il s'agirait d'une pathologie multifactorielle. Ainsi, quelles interventions cliniques seraient nécessaires pour que mère et bébé puissent (ré)écrire ensemble un nouveau récit psychique, qui leur permettrait de développer une véritable capacité à se rencontrer ? Y aurait-il un type de prise en charge clinique spécifique aux bébés à risque d'autisme? Comment la psychanalyse contemporaine, centrée sur l'intersubjectivité et l'inter-psychisme, peut nous aider à comprendre la clinique d'intervention précoce?

[Care pathway diversity of patients with multiple sclerosis between French regions]. / Diversité des prises en charge des patients atteints de sclérose en plaques entre régions françaises.

BACKGROUND: The aim of this study is to analyze and to compare data from 2015, focusing on hospital care for patients with multiple sclerosis from three French regions with different characteristics in terms of prevalence, size and number of multiple sclerosis competencies and resource centers. METHODS: All hospital admissions from the PMSI MCO 2015 database, with a principal or related diagnosis (PD-RD) of G35* ("multiple sclerosis") were extracted. We also extracted chemotherapy treatments administered in hospital, during admissions with a significant associated diagnosis (SAD) of G35*, if the PD or RD was coded Z512 ("non-tumor chemotherapy"). The analyzed regions corresponded to those of 2015, some of which have since merged. RESULTS: There were 95,359 hospital admissions for multiple sclerosis in France in 2015 among a total cohort of 21,102 patients, resulting in a total cost of € 54.1m. Patients with MS were managed mainly in the ambulatory setting, which accounted for 88.5 % of all admissions. The Rhône-Alpes region represented 7.6 % of national admissions for MS, 9.6 % of patients, and 14 % of inpatient days, contributing 10.4 % of the national cost of MS care. 58.4 % of stays were managed by the two main multiple sclerosis centers. The Nord-Pas-de-Calais region represented 9.8 % of national admissions, 10 % of patients, 6.6 % of inpatient days, and 9.1 % of the national cost. 29.8 % of stays were managed by the main multiple sclerosis center. The Centre region represented 2.7 % of stays, 2.8 % of patients, 3.1 % of inpatient days, and 2.8 % of the national cost. 28.4 % of stays were managed by the main multiple sclerosis center. CONCLUSION: This study highlights the diversity of multiple sclerosis hospital management and care between these three regions.

[High blood pressure and obesity: disparities among four French overseas territories]. / Hypertension artérielle et obésité : disparités entre quatre régions d'Outre-mer.

BACKGROUND AND PURPOSE: The epidemiological characteristics of hypertension and obesity in French overseas territories (FOTs) have never been compared. METHODS: This cross-sectional survey included representative population-based samples of 602, 601, 620 and 605 men and women aged more than 15 years, respectively, from four FOTs of Guadeloupe, Martinique, French Guiana, and French Polynesia. Hypertension was defined as blood pressure (BP) at least 140/90mmHg or the current use of antihypertensive treatment. RESULTS: The prevalence of hypertension was 29.2% in Guadeloupe, 17.9% in French Guiana, 27.6% in Martinique and 24.5% in French Polynesia. Considering the Guadeloupe population as the reference group, prevalence of hypertension was significantly lower in French Guiana (P<0.001), even after controlling for age and sex (PU0.006). Awareness and treatment of hypertension were similar in French Guiana, Martinique and Guadeloupe (68.8-75.1% and 69.0-73.4%, respectively). Awareness was lower in French Polynesia (50.0%, adjusted P value U0.04), as was treatment of hypertension (32.4%, adjusted P value U0.001). Control of hypertension was also lower in French Polynesia (8.8%, adjusted P value U0.001) compared with the other territories (29.7-31.8%). French Polynesia had the highest prevalence of obesity (33.1%, adjusted P value<0.001) as compared with the other territories (17.9-22.8%). It had also the largest population attributable fraction of hypertension due to obesity (35.5%) compared with Guadeloupe (13.3%), Martinique (12.3%) and French Guiana (23.6%). CONCLUSION: Wide variations were observed in the prevalence and the management of hypertension between these FOTs, and an especially challenging low control of hypertension was found in French Polynesia. Obesity appears a key target to prevent hypertension, particularly in French Polynesia.