[Psychotic disorder induced by Fahr's syndrome: a case report]. / Trouble psychotique secondaire à un syndrome de Fahr: à propos d'une observation.

UNLABELLED: Fahr's syndrome is a rare disorder characterized by abnormal deposits of calcium in areas of the brain that control movement, including the basal ganglia and the cerebral cortex associated with many neurological and psychiatric abnormalities such as a rigid hypokinetic syndrome, mood disorders and cognitive impairment. Fahr's syndrome is secondary to some disorders, such as hypoparathyroidism. CASE REPORT: We report the case of a 56 year-old man, with a history of cataract, who was admitted to our psychiatric hospital for the first time in his life because of psychotic symptoms associated with irritability and aggressiveness. Since the age of 38 the patient had become nervous, 10 years later he developed tonic-clonic seizures. Two months ago, he began expressing delusions of persecution against his wife and sons and making fugues. According to his family during this period, he was agitated, aggressive, and suffered from insomnia and anorexia. The general and psychiatric examination showed an upright and bronzed patient with neglected hygiene. He was indifferent to his environment and expressed poor mimics and gestures. He was anxious, suspicious and not very talkative. He was conscious but his attention was slightly decreased. Moreover, he was not aware of his problems. The neurological examination showed extrapyramidal syndrome with postural tremor and cerebellar ataxia. A cranial computed tomography brain scan found bilateral, symmetric basal ganglia calcifications, in favour of Fahr's syndrome. Phosphocalcic investigations revealed low concentration of serum calcium at 1.01mmol/L (normal 2.15 to 2.57mmol/L) and hyperphosphoremia at 2.69mmol/L (normal 0.81 to 1.55mmol/L). He also had low concentrations of 25-OH vitamin as well as decreased urinary levels of phosphate and calcium. The blood level of parathyroid hormone was 0ng/L. The diagnosis of Fahr's syndrome, revealing a hypoparathyroidism was posed. He was supplemented with calcium and alpha cholecalciferol and treated with clozapine (100mg per day). After four weeks, psychotic symptoms responded well to this treatment without expressing any side effects, notably seizures. DISCUSSION: Psychotic symptoms seen in Fahr's disease include auditory and visual hallucinations, complex perceptual distortions, delusions, and fugue state. Some of them were manifest in this patient. It is likely that the psychosis in both Fahr's disease and schizophrenia share a similar pathology. Positive psychotic symptoms, hallucinations, and paranoia are not necessarily generated by the classical hypothesis of dopamine-mediated attachment of salience to internally generated stimuli. Still, there is some evidence that disruption of the cortex involved in the pathophysiology of schizophrenia is also seen in Fahr's disease, particularly in areas of the limbic system. CONCLUSION: Psychiatrists should consider Fahr's syndrome as a differential diagnosis in the evaluation of psychosis associated with seizures. This case, along with others in the literature, further emphasizes the importance of the role of neuro-imaging and the search for disrupted phosphocalcic metabolism in patients with atypical psychotic symptoms. Moreover, further research should focus on pharmacologic interventions. The efficacy and risks of neuropharmacologic and psychopharmacologic interventions in Fahr's syndrome, and correlates of good and poor outcome with these interventions remain to be defined.

[Assessing beliefs and attitudes of relatives of patients with schizophrenia: a study in a Tunisian sample]. / Évaluation des croyances et des attitudes d'une population tunisienne de proches de patients atteints de schizophrénie.

INTRODUCTION: Investigating and understanding family member's causal beliefs and attitudes about schizophrenia is an important step in the management of the illness. They likely influence the family's help-seeking decisions and affect both adherence with biomedical interventions and social integration of the patients. The aim of this study was to describe Tunisian families' beliefs about the causes, the symptoms and the treatments of schizophrenia. METHODS: We led a transversal study including 91 relatives of patients with schizophrenia or schizoaffective disorder (DSM-IV). We excluded patients with mental retardation or neurological diseases. For family members, we excluded participants with a history of mental disorders or cognitive impairments. We collected basic socio-demographic data for both patients and relatives. We asked relatives to respond by "yes/no/I am not certain" to a three-part questionnaire including 27 items dealing with causal explanations, symptoms and optimal cures for schizophrenia. RESULTS: The mean age of the relatives was 49.8 (±13.7) years; 54.9% were men; 49.4% were parents, 8.8% spouses, 39.6% brothers or sisters; 25.3% had not attended school, 24.2% had attended primary school, 37.4% junior high school or high school and 13.2% had a university degree; 63.7% lived in an urban area; 33% had low economic status and 41.8% reported having another family member with mental disorder. Only 46.2% of participants had asked psychiatrists about the diagnosis of their sick relatives and only 16.5% were able to label the term "schizophrenia". Among the cited etiologies of schizophrenia, religious causes were found in 76.9% of cases, they first cited God's will or fate and secondly God's punishment. Magical explanations such as witchcraft and possession by "djinns" were found in 47.3% of cases. The biological causes were cited by 59.3% of participants. The majority of participants (95.6%) proved the need for drugs and 81.3% the utility of psychotherapies. However, 30.8% believed in non-medical practices such as reading Holy Koran verses, charity and exorcism. Significant correlations were found between relatives' low level of education, low economic status, living in a rural area and supernatural beliefs, traditional practices, stigma and the use of the term 'madness'. Significant correlations were also found between family history of mental disorders and beliefs on family and hereditary causes. CONCLUSION: In this study, opinions and attitudes regarding schizophrenia were related to education level, economic status and geographic origin. Few persons recognized the term "schizophrenia" despite a long contact with the mental health system. This fact points out the need to improve the psychoeducation of family members of persons with schizophrenia.

[Violence in schizophrenia: a study of 60 cases]. / Les actes de violence dans la schizophrénie: étude à propos de 60 cas.

BACKGROUND: Epidemiological studies suggest a positive but controversial correlation between the major mental disorders, particularly schizophrenia and delinquent or criminal acting out. aim : To study the occurrence of violence in patients with schizophrenia according to demographic, clinical and disease progression features. METHODS: This retrospective study included all out-patients, consulting during a period of one month, suffering from schizophrenia for at least five years. The clinical and forensic history was obtained owing to a semi-structured interview with patients and their families, medical records and the passing of different scales. RESULTS: Sixty patients were included. 46.7% (n=28) of patients had a violent behavior in the pre morbid period. Aggressiveness was noted as the first prodrome in 13.3% (n=8) of cases. 28 major acts of violence were committed by 30% (n=18) of patients regardless of the active period of disease. In 13.3% (n=8) of cases, these acts announced the disease. The majority of acts have been committed against a non-foreign person. Recurrence was noted in 44.4% (n=8) of patients. Several risk factors of violent behavior were found. Only prodromal aggression was associated with a poor prognosis. CONCLUSION: Violences committed by patients with schizophrenia are attributed to a particular group of patients and do not have necessarily a pejorative prognostic value.

[Prodromal symptoms in schizophrenic relapse: A descriptive and comparative study]. / Les prodromes des rechutes schizophréniques : étude descriptive et comparative.

INTRODUCTION: Schizophrenia is a severe, chronic psychiatric disorder. After recovery from a first psychotic episode, 70% of patients have exacerbations. These exacerbations are preceded in 66 to 100% of cases by early signs. Prevention of relapses is the main object of dealing with schizophrenia. In fact, after a psychotic relapse, 17% of patients develop residual symptoms which did not exist before the relapse. Moreover, symptoms resistant to antipsychotics appear in 35% of patients after a relapse. Each relapse increases the risk of future relapses. Finally, the cost of treating patients with relapses is four times higher than in patients without relapses. Prevention of relapses is possible if we detect early signs. In fact, when specific interventions are applied in time, relapses can be avoided. Surprisingly, there is a scarcity of data on prodromal symptoms of schizophrenic relapses in the literature. OBJECTIVE: In this study, we aimed to describe early signs of schizophrenic relapses, which are comparatively more frequent than those in stabilized outpatients. METHODS: We conducted a retrospective, descriptive and comparative trial. We included 30 patients with schizophrenia who had recently experienced a psychotic relapse and a member of their families. We also included a control group of 30 stabilized outpatients with schizophrenia. All of the patients were diagnosed schizophrenic according to the DSM IV and had no secondary diagnosis. Only patients aged from 18 to 55 years and having an illness with an episodic evolution were included. The relapse group must have had a period off illness of more than one year and duration of the last remission greater than 3 months. We built a structured interview based on the data of the literature on early symptoms of relapses and on our clinical experience. It contained 93 items describing symptoms and feelings relevant to the period of relapse. The interview lasted about 1h. We collected demographic information from both groups. The relapse group was composed of 21 men and nine women. Their average age was 34 years and their level of education was 9.3 years. The mean number of hospitalizations was 3.8 and 73.3% of patients had interrupted their medication. The stabilized outpatients group included 25 men and five women with an average age of 40.3 years. The mean level of education was 8.3 years, the number of hospitalizations was 2.7 and 16.7% of patients had interrupted their medication. RESULTS: The mean time interval between the beginning of symptoms and the need for hospitalization was 160.5 days. The more frequent symptoms in the relapse group than in stabilized patients were: overinvested ideas/delusions (93.3% of relapsing patients), trouble sleeping (80%), symptoms of disorganization (80%), and excitement/mood changes (73.3%). Globally, non-specific symptoms precede specific symptoms (149.4 days vs. 94.8 days). The earlier signs were influence syndrome (113.4 days before relapse), verbal aggressions against others (108.1 days) and suicidal thoughts (94.8 days). The latest signs were physical aggression against others (37.3 days), unmotivated smiles (35.4 days), aggression against self (35 days), strange thoughts (30.7 days) and breaking things (25.3 days). CONCLUSION: The time between perception of symptoms and hospitalization in schizophrenic patients in this study was very long (approximately 6 months). Non-psychotic prodromal symptoms precede psychotic symptoms. We recommend a major focus on teaching the patient and his/her family how to recognize early signs of decompensation and what steps to take to ensure effective treatment. We also recommend further research to determine the predictive positive value of early signs of relapse.

Prevalence of gastroesophageal reflux in a Tunisian primary care population determined by patient interview.

Although gastresophageal reflux disease (GERD) is highly prevalent in Western countries, we have very little data about it in African countries. The aim of the study is to determine the prevalence and severity of GERD symptoms among Tunisian subjects and report its characteristics, consultation rate, management modes, as well as patients' satisfaction. Five hundred subjects living in Tunisia were interviewed face to face. The study was conducted at seven centers of primary care at Monastir's department by six interviewer doctors. The questionnaire consisted of 30 questions relating to subject attributes, lifestyle factors, medical history, reflux-related symptom characteristics, consultation behavior, previous treatments for GERD, and description of the last episode. Symptoms were defined as 'frequent' if they occurred at least weekly and 'occasional' if they occurred less frequently during the last year. The mean age was 42.3 ± 17.3 years and 75.6% were females. Over the previous year, 60% of the respondents reported suffering any GERD symptom. The prevalence of frequent GERD is 24%. Female gender (odds ratio [OR]: 1.97[1.15-3.37]) and body mass index ≥ 25 (OR: 1.54[1.042-2.29]) were associated with increased risk of GERD symptom. Only 22.3%, sought medical advice about GERD symptoms in the last year. In the univariate and multivariate analysis, work status, frequency and intensity of symptoms, duration of symptom, and association of atypical symptoms were associated with a higher frequency of medical consultation for GERD symptoms. Among the subjects complaining about heartburn, 34% took medications. GERD symptoms are common among Tunisian subjects. Few heartburn sufferers seek medical attention, and most do not take medications for symptomatic control.

[Hepatorenal syndrome]. / Le syndrome hépato rénal.

BACKGROUND: Hepatorenal syndrome (HRS) is a particular form of functional renal failure which may develop in patients with liver cirrhosis. Recent advances in the understanding of the biology of vasoactive mediators and the physiology of microcirculation have allowed to better anticipate its pathophysiological mechanisms. AIM: To review new advances in the knowledge of epidemiology, diagnosis criteria, pathophysiological mechanisms and treatment of HRS. METHODS: Review of literature using medical data bases (Medline) with the following key words: hepatorenal syndrome, pathophysiology, medical treatment, MARS, liver transplantation. RESULTS: During the course of cirrhosis, portal hypertension leads to splanchnic and systemic vasodilation, responsible for a reduction of effective arteriel blood volume. As a result, a state of intense renal vasoconstriction develops, leading to renal failure in the absence of any organic renal disease. At this stage, liver transplantation is the only definitive therapy able to reverse renal dysfunction. Pharmacologic and radiologic therapy is aimed at improving renal function to enable patients to survive until transplantation is possible. These therapies are based on vasoconstrictor drugs associated with intravenous albumin infusion and transjugular intrahepatic portosystemic shunt (TIPS). They improve circulatory function, normalize serum creatinine and may improve survival. CONCLUSION: Simple measures have been shown to reduce the risk of HRS in cirrhotic patients including the plasma volume expansion with albumin in patients with spontaneous bacterial peritonitis and optimal fluid management in patients undergoing large volume paracentesis.

[What are the distinctive characteristics of subjects with frequent and occasional gastroesophageal reflux symptoms?]. / Quels sont les caractéristiques distinctives entre les patients ayant un RGO fréquent et les reflueurs occasionnels?

BACKGROUND: The aim of this study was to determine the prevalence and clinical spectrum of gastroesophageal reflux disease (GERD) in Tunisia and to compare the characteristics and disease management of subjects complaining of at least weekly and less frequent gastroesophageal reflux symptoms. METHODS: Five hundred subjects living in Tunisia were interviewed face to face. The questionnaire consisted of 30 questions relating to subject attributes, lifestyle factors, medical history, reflux-related symptom characteristics, consultation behavior, previous treatments for GERD and description of the last episode. RESULTS: The mean age was 42.3±17.3 years and 75.6% were females. Sixty percent of the responders reported at least one GERD symptom. The prevalence of frequent GERD was 24%. Only 22.3% had sought medical advice about GERD symptoms in the last year. Of those who had consulted, 75% of individuals waited over 6 months before consulting a physician. Compared with subjects with occasional gastroesophageal reflux symptoms, those with frequent symptoms suffered from more severe symptoms, (OR: 3.5; CI 95%: 1.9-6.4), had more often sought medical advice (OR: 2.9 CI 95%: 1.6-5.2) and had more often used a drug therapy for GERD (OR: 2.2; CI 95%:1.3-3.8). In the multivariate analysis, work status, frequency and intensity of symptoms, duration of symptoms and association of atypical symptoms were associated with a higher frequency of medical consultation for GERD symptoms. CONCLUSION: GERD symptoms are common in the Tunisian population. The population with frequent GERD exhibits more severe symptoms and greater healthcare use.

Polyunsaturated fatty acids deficits are associated with psychotic state and negative symptoms in patients with schizophrenia.

The study was aimed to examine membrane polyunsaturated fatty acids (PUFAs) profile in patients with schizophrenia (SZ) before and after antipsychotic medication and test their association with psychopathology. Erythrocyte membrane fatty acids were analysed by gas chromatography in 36 drug-free patients with SZ and 36 controls. Psychometric evaluation and blood sampling were achieved at baseline and after 3 months of antipsychotic treatment. At enrolment, levels of total PUFAs and arachidonic (AA) and docosahexaenoic (DHA) acids were significantly lower, but ω6/ω3 PUFAs ratio was higher in patients. AA and DHA were negatively related to the Andreason's scale for assessment of negative symptoms (SANS) score. DHA was inversely related to "alogia", "anhedonia", "avolition", and "blunted affect" subitems of SANS. After 3 months under typical antipsychotic drugs, fatty acid profile turned into comparable to controls in parallel with psychopathology improvement. Data indicate that PUFAs deficits are associated with psychotic state and negative symptoms of SZ.

[An overview of premenstrual syndrome]. / Le syndrome prémenstruel: revue générale.

Premenstrual syndrome (PMS) is a recurrent disorder that occurs in the luteal phase of the menstrual cycle. It is characterized by intense physical, psychological, and behavioral changes that interrupt interpersonal relationships and disrupt the lives of affected women. Premenstrual syndrome is believed to affect 75% of women of childbearing age. Because no tests can confirm PMS, the diagnosis should be made on the basis of a patient-completed daily symptom calendar and the exclusion of other medical disorders. PMS symptoms occur during the luteal phase of the menstrual cycle and remit with the onset of menstruation or shortly afterward. The aetiology of PMS is still unknown uncertain, but are likely associated with aberrant responses to normal hormonal fluctuations during the menstrual cycle. A wide range of therapeutic interventions has been tested in the treatment of premenstrual symptoms. Most non-pharmacological interventions that have been proven efficacious require a series of interventions. If non-medical approaches are ineffective, drug therapy may be appropriate. Several pharmaceutics agents have been shown to relieve symptoms. Calcium carbonate and selective serotonin reuptake inhibitors have demonstrated excellent efficacy.

[Cholestatic jaundice secondary to portal cavernoma: Case report]. / Ictère cholestatique secondaire à un cavernome porte: à propos d'un cas.

Portal biliopathy is due to compression of the common bile duct by varicose veins constituting portal cavernoma. Usually asymptomatic, it can occasionally be responsible for jaundice or cholangitis. We report a case of portal cavernoma secondary to pylephlebitis complicating acute appendicitis, followed eleven years later by occurrence of cholestatic jaundice. Diagnosis of portal biliopathy was done by imaging and confirmed by endoscopic retrograde cholangiography with insertion of a plastic stent into common bile duct. This stent was periodically changed and allowed regression of jaundice with a 3-year follow-up. Through a review of the literature, both clinical and therapeutic characteristics of portal biliopathy were studied.