Cerebellar parcellation in schizophrenia and bipolar disorder.

OBJECTIVE: The cerebellum is involved in cognitive processing and emotion control. Cerebellar alterations could explain symptoms of schizophrenia spectrum disorder (SZ) and bipolar disorder (BD). In addition, literature suggests that lithium might influence cerebellar anatomy. Our aim was to study cerebellar anatomy in SZ and BD, and investigate the effect of lithium. METHODS: Participants from 7 centers worldwide underwent a 3T MRI. We included 182 patients with SZ, 144 patients with BD, and 322 controls. We automatically segmented the cerebellum using the CERES pipeline. All outputs were visually inspected. RESULTS: Patients with SZ showed a smaller global cerebellar gray matter volume compared to controls, with most of the changes located to the cognitive part of the cerebellum (Crus II and lobule VIIb). This decrease was present in the subgroup of patients with recent-onset SZ. We did not find any alterations in the cerebellum in patients with BD. However, patients medicated with lithium had a larger size of the anterior cerebellum, compared to patients not treated with lithium. CONCLUSION: Our multicenter study supports a distinct pattern of cerebellar alterations in SZ and BD.

[Clinical efficacy and achievement of a complete remission in depression: increasing interest in treatment with escitalopram]. / Efficacité clinique et obtention d'une rémission complète dans la dépression : intérêt de l'escitalopram.

Such a prevalent disease as Major Depressive Disorder (MDD), associated with prominent impairment in physical and social functioning, implies as well an increased morbidity and mortality. Long-term treatments are required due to the frequent occurrence of relapses. Patient compliance is a core factor in both acute and continuation treatment, closely related to tolerability issues. We have partially reviewed the literature published on PubMed since 2004 which assess the relative antidepressant efficacy of escitalopram and comparator antidepressants in adult patients who met DSM-IV criteria for major depressive disorder (MDD). Clinically important differences exist between commonly prescribed antidepressants. These analyses are in favor of a superior efficacy and tolerability of long-term escitalopram treatment (10 to 20mg/day) compared with active controls, including selective serotonin re-uptake inhibitors (SSRIs) (paroxetine, citalopram, bupropion, fluoxetine, fluvoxamine, sertraline), serotonin/noradrenaline reuptake inhibitors (SNRIs) (venlafaxine, milnacipran and duloxetine) and noradrenergic and specific serotonergic antidepressants (NaSSAs) (mirtazapine). Cipriani et al. (2009) have performed a network meta-analysis of 12 new generation antidepressants. They have shown that clinically important differences exist between commonly prescribed antidepressants for both efficacy and acceptability in favor of escitalopram and sertraline in acute treatment, defined as 8-week treatment. Kasper et al. (2009) conducted a post-hoc pooled analysis of data from two 6-month randomized controlled trials that revealed superior efficacy and tolerability of escitalopram when compared with paroxetine. The pooled analysis of four randomized, double-blind, active comparator, 6-month trials in MDD, by Wade et al. (2009), showed that short-term outcomes may predict long-term treatment compliance and outcomes. A higher probability of achieving remission was associated with responding after 8 weeks and with completing 6 months of treatment. Furthermore, Week 24 complete remission (MADRS≤5) was significantly (P<0,01) higher for escitalopram (51.7%) than for the pooled comparators (45.6%). And after 6 months, fewer patients discontinued treatment with escitalopram (15.9%) than with the pooled comparators (23.9%) (P<0.001). This fragmentary review of the literature shows that it is necessary to adopt a stringent definition of remission in depression, especially in clinical trials; a MADRS total score less or equal to 10 to define remission, a MADRS total score less or equal to 5 to define complete remission, and moreover no MADRS single item greater than 1 to define symptom-free remission. In all these meta-analyses, the superiority of escitalopram compared with other antidepressants was confirmed for both acute and long-term treatment of MDD, especially in harshly depressed patients.

Biomechanical consequences of first metatarsal osteotomy in treating hallux valgus.

BACKGROUND: Among the numerous osteotomies for correction of hallux valgus, the modified chevron is known for its good intrinsic stability and the scarf for its large corrective potential. An intermediate design, the reversed-L osteotomy, has been developed to combine these competing biomechanical objectives. The purpose of this in vitro study was to compare the structural and local biomechanical performance of these three designs. METHODS: Stiffness, cortical bone strains (a factor relevant to bone remodeling), strength and failure mode of the scarf, modified chevron and reversed-L osteotomies were measured on human specimens in two different loading configurations. FINDINGS: The scarf osteotomy caused significant changes in stiffness and cortical bone strains with the proximal apex being at the origin of bone failure. The chevron and reversed-L had a generally comparable response to the intact bone. The chevron specimens failed by pivoting of the distal fragment, and the reversed-L by pivoting or fracture. INTERPRETATION: This is the first study to investigate the cortical bone strain changes induced by these invasive osteotomies. Alterations from the intact bone response could be directly related to the design of the osteotomy. Notably, the critical weakening proximal apex of the scarf is avoided in the reversed-L, leading to results comparable to the chevron. This study provides support in favor of the intermediate design of the reversed-L as an effective compromise between the competing biomechanical objectives of corrective potential and mechanical stability.

Misalignment of total ankle components can induce high joint contact pressures.

BACKGROUND: A major cause of the limited longevity of total ankle replacements is premature polyethylene component wear, which can be induced by high joint contact pressures. We implemented a computational model to parametrically explore the hypothesis that intercomponent positioning deviating from the manufacturer's recommendations can result in pressure distributions that may predispose to wear of the polyethylene insert. We also investigated the hypothesis that a modern mobile-bearing design may be able to better compensate for imposed misalignments compared with an early two-component design. METHODS: Two finite element models of total ankle replacement prostheses were built to quantify peak and average contact pressures on the polyethylene insert surfaces. Models were validated by biomechanical testing of the two implant designs with use of pressure-sensitive film. The validated models were configured to replicate three potential misalignments with the most CLINICAL RELEVANCE: version of the tibial component, version of the talar component, and relative component rotation of the two-component design. The misalignments were simulated with use of the computer model with physiologically relevant boundary loads. RESULTS: With use of the manufacturer's guidelines for positioning of the two-component design, the predicted average joint contact pressures exceeded the yield stress of polyethylene (18 to 20 MPa). Pressure magnitudes increased as implant alignment was systematically deviated from this reference position. The three-component design showed lower-magnitude contact pressures in the standard position (<10 MPa) and was generally less sensitive to misalignment. Both implant systems were sensitive to version misalignment. CONCLUSIONS: In the tested implants, a highly congruent mobile-bearing total ankle replacement design yields more evenly distributed and lower-magnitude joint contact pressures than a less congruent design. Although the mobile-bearing implant reduced susceptibility to aberrant joint contact characteristics that were induced by misalignment, predicted average contact stresses reached the yield stress of polyethylene for imposed version misalignments of >5 degrees.

The role of the subscapularis in preventing anterior glenohumeral subluxation in the abducted, externally rotated position of the arm.

BACKGROUND: Current literature suggests that the subscapularis muscle is the main active stabilizer when the humerus is abducted and externally rotated. Conservative treatment of anterior shoulder instability therefore aims at strengthening this muscle. Empirical models, however, have questioned the role of the subscapularis muscle as it has been observed to potentially support dislocation of the subluxated humeral head. METHODS: Ten human shoulders were loaded with an anterior dislocating force and the effect of different subscapularis tensions on humeral translation was measured with the Motion Analysis system, for the abducted and externally rotated arm and neutral positions. Also, lines of action of the subscapularis segments were measured on a 3D epoxy model. FINDINGS: Shoulders in which the humeral head migrated antero-superiorly under an external antero-inferior load were observed to dislocate under simulated active subscapularis tension in both positions. In contrast, shoulders in which the head migrated antero-inferiorly remained stable. Twice as many specimens dislocated in the abducted - externally rotated position than in the neutral position. The change in line of action of the subscapularis may account for this change. INTERPRETATION: Exercises alone are unlikely to be adequate for all patients with anterior instability symptoms. Passive motion pattern of the humeral head might serve as an indicator as to whether the effect of strengthening the subscapularis might stabilize a shoulder without further operation. Development of a clinical test based on these findings might differentiate the non-operative from operative candidates among patients presenting with anterior instability of the shoulder.

[The information of the schizophrenic patient: actuality]. / L'information du sujet schizophrène en pratique clinique: données actuelles.

Social isolation has got to be one of the greatest losses in schizophrenia. For many authors, people with schizophrenia can have no friends, no spouse, and sometimes no family. Two thirds of patients with schizophrenia return to their parents' house after discharge from a hospital for the first psychosi episode. Family members generally receive very little education as to what they can expect. They may not know the importance of medication compliance. Family members are the primary victims of violence from psychotic individuals, usually their own son or daughter, and most families cannot believe their own son or daughter would be capable of such a thing. Although families are usually the main care givers at the beginning of schizophrenia they often find their experience very frustrating for a number of reasons, and relationships suffer. Family education and support have been shown to improve outcomes considerably and family education is the second strongest factor in relapse prevention. Without education and good relapse prevention families often burst out. Most of the homeless mentally ill in downtown city cores have lost their family relationships. It is not a reflection on their families so much as the lack of adequate treatment and support. The families tried and tried and lost their ill relative. A patient writes: "My father lives just outside of Monaco. My mother developed Alzheimer's a couple of years ago or so and with a series of mild strokes died recently. I haven't seen either of them very much in the last fifteen years. I have a sister, Nicole, who also lives in Paris. I lost those relationships to some degree over the years. I am rebuilding them now. Enter the professional friend, the case manager, usually in cases where the individual is quite disabled by schizophrenia and/or at considerable risk of relapse, and usually when the individual has lost their family relationships to some degree. I had a case manager for several years and always looked forward to her visits. Case managers help negotiate compliance to medication, housing, meaningful activity, substance abuse, poverty, isolation, and everything else living in the community can throw at you. Without a spouse you tend to spend a lot of time alone. One of the main reasons Marie-Claude and I moved in with each other was that neither of us was enjoying living alone. It was very romantic at first but now we are just friends who see less and less of each other. I suspect schizophrenia interferes with the quality and depth of relationships you have with other people. Amongst the people I know, schizophrenia has meant a pretty solitary life of poverty. I have a lot of acquaintances, and colleagues, but few close friends when not at work. Over the last ten years of living with schizophrenia on medication it is celibacy that has hurt the most. It saps the life out of you, your self confidence, your self esteem. In some Scandinavian countries and Holland disabled people are allowed monthly visits by state approved sex workers. To me that is only common sense. To live without sex is unnatural and can only cause emotional suffering. We don't recognize the importance of quality sexual experience in keeping people healthy and happy in France. That doesn't mean it isn't I have a pretty high profile in my community through the meaningful activity I do. From having a half dozen names and faces to remember, I now have what seems like hundreds. I have a lot of trouble remembering people's names and faces. I am still meeting new people but I'm rarely invited to socialize with any after work. They have families, full time jobs, kids, cars, cottages, etc. My life at home is pretty solitary. It's a nuisance to travel across the city to visit people. There are few people that I share a similar background with. Since people with schizophrenia tend to have trouble learning new things, and change very little as a result, we tend to have trouble making new friends. People with schizophrenia can come alive talking about things in the past before they became ill. It's as if their life grinded to halt when they became sick. I'm stuck in the mid seventies, and that's the music I like. Everybody I know with schizophrenia is quite isolated socially and I don't really know why. That is especially true for the older people in my age group. Younger people seem to be doing much better. Many still live with their parents. Most older people live alone. There is also the odd person who recovers well, returns to a career, and marries someone without schizophrenia. In cases where marriage predates the onset of schizophrenia, the outcome is often divorce although women are more likely to stick with their husbands with schizophrenia than vice versa, especially if there are already children. I hope the next generation who appears to be less disabled survives better than people of my age with schizophrenia. The goal of community integration is one that requires: more effective treatments and/or more financial support and/or a compassionate non-discriminating community. The combination of early diagnosis and atypical medications will change the face of schizophrenia. I'm not expecting more financial support from the government, but many more people with schizophrenia will start working again instead. Their social networks will develop but social networks are probably the hardest hit in schizophrenia. It's better that you never lose your friends in the first place". This testimony shows how the information of the schizophrenic patient is necessary, and underlines the importance of the relationships between the patient and his family. Our article insists on this theme, rarely developed in the literature.

Uncemented short-length diaphyseal segmental replacement prosthesis fixation--finite element analysis and long-term results.

INTRODUCTION: Extensively porous coated segmental replacement prostheses with intramedullary cementless fixation to bone over the whole length of stem often exhibit resorption of the surrounding bone due to stress-shielding. This makes them particularly susceptible to aseptic loosening. STUDY: A finite element analysis of the state of loading of a short-length fixation in a new prosthetic stem design has shown a definite advantage over long-length fixation. The stress pattern within the bone surrounding the prosthesis confirmed that shortening of the ongrowth area in length increases the stress values at the resection level significantly. This stem (Endlock) has been used for diaphyseal anchorage in the treatment of tumors in combination with an artificial joint of proven design in order to reduce stress shielding. RESULTS: No Endlock stem fractures or aseptic loosenings were observed at recent follow-up. The early clinical results comply with the theoretical assumptions. CONCLUSIONS: A short-length fixation system based on intramedullary anchorage of segmental replacement endoprostheses would possibly support physiologic adaptive processes more than fixation over the full length of the stem.

[Characteristics of patients hospitalized in a specialized hospital center after after attempted suicide]. / Caractéristiques des patients hospitalisés dans un centre hospitalier spécialisé après une tentative de suicide.

Authors have counted, during a period of one year, the totality of patients having been admitted to the Centre Hospitalier Spécialisé de la Savoie (Chambéry) following a volunteer medicinal intoxication; 227 patients have been thus included, this type of acting out concerning third more women than men. The higher impact is found in young adults (20-40 years). Professional inactivity appears as a favoring factor, while the way of life (bachelor or in couple) does not seem to have consequence on the frequency of occurrence of the suicidal attempts. Relapses are numerous, and happen in most cases during the year. Concerning used medicines, they have been generally prescribed by a practitioner or a psychiatrist. The prominent fact is the presence of a very short period between the prescription, the deliverance of the medicine and the acting out. Plurimedicinal intoxications are increasingly frequent, with often concurrent absorption of alcohol. The diminution of the use of barbiturics in ambulatory medicine to the profit of other molecules, and especially the benzodiazepines, has reduced the frequency of their use in volunteers medicinal intoxications. Benzodiazepines are the most employed medicines in this type of acting out. This epidemiological and toxicological study confirms that used substances during volunteer medicinal intoxication are a reflection of the general medicinal consumption.

[Restraint and seclusion in psychiatry: review and prospects]. / Isolement thérapeutique et contention en psychiatrie: bilan et perspectives.

In this article, the authors reviewed the literature published since 1965 concerning restraint and seclusion. They synthesized the contents of the articles reviewed using the categories of indications and contraindications; rates of seclusion and restraint as well as demographic, clinical, and environmental factors that affect these rates; effects on patients and staff; implementation; and training. The literature on restraint and seclusion supports the following: 1) Seclusion and restraint are basically efficacious in preventing injury and reducing agitation; 2) It is nearly impossible to operate a program for severely symptomatic individuals without some form of seclusion or physical or mechanical restraint; 3) Demographic and clinical factors have limited influence on rates of restraint and seclusion; 4) Training in prediction and prevention of violence, in self-defense, and in implementation of restraint and/or seclusion is valuable in reducing rates and untoward effects; 5) Studies comparing well-defined training programs have potential usefulness.

[Vulnerability to schizophrenia. III: Importance and limits of the Identical Pairs Continuous Performance Test]. / Vulnérabilité à la schizophrénie. III: Intérêts et limites du test de performances continues à paires identiques (CPT-IP).

Since several investigations have shown attentional deficits both in patients with schizophrenia and in subjects at high risk for schizophrenia, these deficits could be valuable vulnerability markers for schizophrenia. The aim of this study was to investigate wether non psychotic relatives of schizophrenic probands have deficits in sustained attention as measured by the Continuous Performance Test, Identical Pairs (CPT-IP) version. The study subjects were 25 schizophrenic probands, 50 of their first-degree relatives and 46 normal controls. For each subject, attention was assessed during 6 experimental conditions (2 standard, 2 slow, 2 easy conditions) of visual stimuli (digit-numbers and shapes). In each of the six conditions, the value of the sensitive index d' in the first-degree relative group was at an intermediate level between the patient and control groups. Moreover, in the standard shape condition, the d' value was significantly lower in the schizophrenic and in the relative groups than in the control group. This deficit was all the more interesting since it was not explained by a deficit in general intellectual abilities or by psychopathology such as anxiety or depression. Furthermore, the schizophrenic patients made more random errors in the standard and in the slow number conditions than both other groups. All groups improved their performance when the stimulus duration increased and when the processing load decreased. As a conclusion, this investigation seems: 1) to confirm the existence of an attentional deficit in the first-degree relatives of patients with schizophrenia; 2) to demonstrate the interest of the CPT-IP to detect this deficit. It must be emphasized that in order to detect the deficit, one only needs to explore the standard shape condition and that under such circumstances, the CPT-IP test has the advantage of being less time consuming than tests used in previous studies.

[Apropos of using patient isolation in psychiatry: point of view of nurses]. / A propos de l'utilisation de l'isolement en psychiatrie: le témoignage des soignants.

Seclusion continues to be used in the care of acutely disturbed psychiatric patients despite often emotionally charged debate about its appropriateness within mental health services. Powerful legal and moral arguments about the use of seclusion emphasize an urgent need to critically examine its role in the care of mentally ill people. This paper examines the use of seclusion on psychiatric departments in the management of acutely disturbed patients: 36 psychiatric nurses working in 6 departments in a specialized hospital (the CHS de la Savoie, in Chambery) were interviewed in relation to their perceptions of the role of seclusion. Data were analysed using grounded theory methodology revealing the core conceptual category "controlling" and two sub-categories "watching out for" and "watching over". Seclusion was found to be used as an adjunctive treatment in the care of individuals considered to be "out of control". Clinicians expressed comfort with the use of seclusion, citing a strict protocol that provided parameters for its use. While expert therapeutic interventions were described by clinicians, they are contextualized within a framework of power and control--a framework that stands in stark contrast to contemporary philosophies of nursing care, providing impetus for a reconsideration of the use of constraining practices in the care of mentally ill people.

Examiner agreement on periodontal indices during dental surveys of elders.

Indices used to evaluate periodontal health have been widely accepted in epidemiological studies, yet their reliability cannot be guaranteed. The aim of this study was to evaluate the reliability of periodontal indices applied on elders. 19 elderly subjects, 73-years-old on average, were examined at a 1st appointment by 2 independent examiners. They were re-examined 2 weeks later during a 2nd session. The examinations were performed in a dental chair with good illumination. Periodontal health was evaluated using the community periodontal index of treatment need, and tooth mobility was evaluated using 2 different indices. Inter and intra-examiner agreements were evaluated using kappa statistics. Taken as an overall measurement, the CPITN was a reliable assessment of periodontal treatment need in elders. Disagreement occurred mainly on the evaluation of bleeding and shallow pockets. The detection of fairly mobile teeth was reliable; however, the performance of the more sensitive scale was deceptive. it seems that, in the case of tooth mobility, a choice has to be made between sensitivity or reproducibility. It can be concluded that examiners should be trained carefully since the reliability of the CPITN and tooth mobility evaluation were good but close to a critical level for which an agreement is classified as poor.

Examiner agreement on caries detection and plaque accumulation during dental surveys of elders.

Indices used to evaluate plaque accumulation and coronal caries have been widely accepted in epidemiological studies, yet their reliability cannot be guaranteed. The aim of this study was to evaluate the reliability of clinical criteria used in coronal and root caries diagnosis and oral hygiene evaluation as applied in elders. Nineteen elderly subjects, 73 years old on average, were examined at a first appointment by two independent examiners. They were re-examined two weeks later. Plaque accumulation was evaluated using the Plaque Index (PI) and coronal and root caries were detected according to the WHO criteria and Fejerskov et al. (1991), respectively. Recurrent caries was recorded as recommended by WHO and by probing at the interface tooth-restoration. Inter- and intra-examiner agreement was evaluated using kappa statistics. The PI score showed good reliability except for examiner b, for whom a simplification of the 4-point scale in 3-point scale improved significantly the reliability. The prevalence of coronal caries was very low and intra- and inter-examiner agreement was poor. Most of the root caries lesions were covered by plaque and the kappa values indicated only poor agreement. Recurrent caries were found with good agreement using WHO criteria but the detection with the probe was not reliable. In conclusion, it seems that examiners should be trained carefully to maximise their reliability and that plaque should be removed to obtain reliable diagnoses of caries. Retraining and calibration may be necessary for surveys continuing over a long period.