[Catatonia de novo, report on a case: immediate vital prognosis and psychiatric prognosis in longer term]. / Catatonie de novo, à propos d'un cas: pronostic vital immédiat et pronostic psychiatrique à plus long terme.

We report on the case of a 20 year old woman with no previous psychiatric history, who displayed a first episode of catatonia with acute onset. Symptoms started plainly with sudden general impairment, intense asthenia, headache, abdominal pain and confusion. After 48 hours, the patient was first admitted to an emergency unit and transferred to an internal medicine ward afterwards. She kept confused. Her behaviour was bizarre with permanent swinging of pelvis, mannerism, answers off the point and increasingly poor. The general clinical examination was normal, except for the presence of a regular tachycardia (120 bpm). The paraclinical investigations also showed normal: biology, EEG, CT Scan, lumbar puncture. Confusion persisted. The patient remained stuporous, with fixed gazing and listening-like attitudes. She managed to eat and move with the help of nurses but remained bedridden. The neurological examination showed hypokinaesia, extended hypotonia, sweating, urinary incontinence, bilateral sharp reflexes with no Babinski's sign and an inexhaustible nasoorbicular reflex. The patient was mute and contrary, actively closed her eyes, but responded occasionally to simple instructions. For short moments, she suddenly engaged in inappropriate behaviors (wandering around) while connecting back to her environment answering the telephone and talking to her parents. The patient's temperature rose twice in the first days but with no specific etiology found. During the first 8 days of hospitalization, an antipsychotic treatment was administered: haloperidol 10 mg per os daily and cyamemazine 37.5 mg i.m. daily. Despite these medications, the patient worsened and was transferred to our psychiatric unit in order to manage this catatonic picture with rapid onset for which no organic etiology was found. On admission, the patient was stuporous, immobile, unresponsive to any instruction, with catalepsy, maintenance of postures, severe negativism and refusal to eat. A first treatment by benzodiazepine (clorazepate 20 mg i.v.) did not lead to any improvement. The organic investigations were completed with cerebral MRI and the ruling out of a Wilson's disease. Convulsive therapy was then decided. It proved dramatically effective from the first attempt; 4 shocks were carried out before the patient's relatives ask for her discharge from hospital. The patient revealed she had experienced low delirium during her catatonic state. The clinical picture that followed showed retardation with anxiety. She was scared with fear both for the other patients and the nursing team. She kept distant and expressed few affects. The treatment at the time of discharge was olanzapine 10 mg per os. She was discharged with a diagnosis of catatonia but with no specific psychiatric etiological diagnosis associated. She discontinued her follow-up a few weeks later. After one year, we had no information about her. Catatonia has now become rare but remains a problem for clinicians. We reviewed data concerning short term vital prognosis and psychiatric long term prognosis in catatonia. Lethal catatonia is associated with acute onset, both marked psychomotor and neurovegetative symptoms. In the light of literature, there is no proband clinical criterion during the episode that is of relevant diagnostic value to ascertain the psychiatric etiology.

Carpal tunnel syndrome: validation of an interview questionnaire on occupational exposure.

The objectives of this study were 1) to summarize in a clinically meaningful way information on occupational risk factors for carpal tunnel syndrome (CTS), and 2) to test a questionnaire on risk factors that could be used by physicians with their patients. For the two objectives, a systematic literature review was performed and synthetized graphically, and a questionnaire was developed and administered to 238 patients who underwent release surgery for CTS. Patients were classified in four groups according to the incidence rate of CTS surgery in their occupation. Answers to the questionnaire on exposure to risk factors for CTS were compared between these four groups with the hypothesis that the group with the highest incidence would report the highest exposure. The results showed that questioning workers on the amount of force required to perform tasks that are "especially demanding" for the wrists or hands is both useful clinically and valid to be used by the clinician to make a judgement on the occupational nature of CTS. Repetitiveness and segmental exposure to vibrations or to cold are potentially useful and will need further validation. There is no evidence at present that posture or motion of the wrists is potentially useful to describe occupational exposure when questioning patients with CTS.

Carpal tunnel syndrome: what is attributable to work? The Montreal study.

OBJECTIVE: To estimate the fraction of carpal tunnel syndrome (CTS) that is attributable to work in the total adult population of the island of Montreal. METHODS: The population consisted of 1.1 million people 20-64 years of age, with 73.2% of men and 60.6% of women employed. The rates of first surgery for CTS were compared between occupational groups and the total adult population with the standardised incidence ratio (SIR) method. Rates of surgery for the island of Montreal were obtained from the provincial data base of payments. The occupational history was obtained from telephone interviews of a sample of surgical cases. The attributable fractions in exposed people were calculated with odds ratios (ORs) obtained from logistic regressions with non-manual workers as the control group. RESULTS: The surgical incidence of CTS was 0.9/1000 adults. SIRs for all manual workers were 1.9 (95% confidence interval (95% CI) 1.4-2.5) in men and 1.8 (95% CI 1.4-2.2) in women, and the fractions attributable to work were 76% (95% CI 47-88) and 55% (95% CI 33-69), respectively. Seven occupational groups were identified as having excess risk of surgical CTS, with fractions attributable to occupation ranging from 75% to 99%. CONCLUSION: Among manual workers on the island of Montreal, 55% of surgical CTS in women and 76% in men was attributable to work. Increased risk of surgical CTS was found in seven occupational groups.

Acute bacterial meningitis. The pathophysiological sequence of events.

Despite the availability of a new vaccine, acute bacterial meningitis continues to be a potentially life-threatening childhood disease. The mortality rate is approximately 5% and research suggests that many of the survivors suffer from various forms of morbidity. The pediatric intensive care nurse must immediately recognize the signs and symptoms of impending complications so that interventions can be implemented before it becomes impossible to reverse a critical situation and/or to prevent longterm sequelae. Therefore nursing care requires a thorough understanding of the pathophysiological sequence of events of this disease process.