Aims: Violent suicide attempt, such as jumping from a height, frequently leads to hospitalization in general hospital with high length of stay. However, features associated with length of stay after ...such suicide attempts remain largely unknown. We aimed to investigate socio-demographic and clinical factors associated with length of stay in general hospital in patients admitted after suicide attempts by jumping. Methods: Patients admitted after suicide attempts by jumping between 2008 and 2016 were included in this study. A wide range of data was collected retrospectively. Length of stay was log-transformed and general linear models were used to identify its associations with socio-demographic and clinical factors. Results: The final sample consisted of 225 patients: 42% received a diagnosis of psychotic disorder (F2 code), 26% a diagnosis of affective disorder (F3 code) and 32% (another diagnosis or no diagnosis). Several clinical factors were associated with a longer length of stay: number of injuries (β=0.17 p=0.01), anticoagulation (β=0.62 p<0.001), external fixator (β=0.39 p=0.02), psychotic disorder (β=0.37 p=0.01) and delirium, (β=0.40 p=0.002). Admission in psychiatric ward at discharge was associated with a lower length of stay (β=-0.82 p<0.001). Conclusion: In patients admitted in medical setting after suicide attempt by jumping, some psychiatric factors, such as psychotic disorder or delirium, may increase the duration of hospital stay by several days (+24 and 29 respectively). The impact on length of stay was nearly similar to those of medical non psychiatric factors, such as anticoagulation or external fixator. In contrast, transfer in psychiatric ward may decrease the length of stay (-6days) suggesting that medical care might have been interrupted due to the psychiatric disorder.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
During the past decade, a large amount of work on transcranial magnetic stimulation (TMS) has been performed, including the development of new paradigms of stimulation, the integration of imaging ...data, and the coupling of TMS techniques with electroencephalography or neuroimaging. These accumulating data being difficult to synthesize, several French scientific societies commissioned a group of experts to conduct a comprehensive review of the literature on TMS. This text contains all the consensual findings of the expert group on the mechanisms of action, safety rules and indications of TMS, including repetitive TMS (rTMS). TMS sessions have been conducted in thousands of healthy subjects or patients with various neurological or psychiatric diseases, allowing a better assessment of risks associated with this technique. The number of reported side effects is extremely low, the most serious complication being the occurrence of seizures. In most reported seizures, the stimulation parameters did not follow the previously published recommendations (Wassermann, 1998) 430 and rTMS was associated to medication that could lower the seizure threshold. Recommendations on the safe use of TMS / rTMS were recently updated (Rossi et al., 2009) 348, establishing new limits for stimulation parameters and fixing the contraindications. The recommendations we propose regarding safety are largely based on this previous report with some modifications. By contrast, the issue of therapeutic indications of rTMS has never been addressed before, the present work being the first attempt of a synthesis and expert consensus on this topic. The use of TMS/rTMS is discussed in the context of chronic pain, movement disorders, stroke, epilepsy, tinnitus and psychiatric disorders. There is already a sufficient level of evidence of published data to retain a therapeutic indication of rTMS in clinical practice (grade A) in chronic neuropathic pain, major depressive episodes, and auditory hallucinations. The number of therapeutic indications of rTMS is expected to increase in coming years, in parallel with the optimisation of stimulation parameters.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Conversion disorder refers to the occurrence of neurological-like symptoms or deficits that are neither intentionally produced nor simulated. While it cannot be explained by an organic disease, it is ...often related to psychological events.
We report the case of a 33-year-old patient with a fluctuating hysterical tetraplegia, which had started three years earlier. After the failure or the exhaustion of several biological (psychotropic medication, transcranial magnetic stimulation) and psychotherapeutic strategies, treatment with electroconvulsive therapy (ECT) was conducted. A total of thirty-five ECT sessions were performed. Whereas the patient's clinical state was initially characterized by a complete quadriplegia and an uncontrollable muscular hypertonia, we noted that the ECT sessions were associated with a slow, though remarkable, progress. At first, the sessions were followed by moments of altered consciousness during which the patient would be relaxed and could make simple movements. Secondarily, not only was our patient able to consciously move his four limbs, but he was also able to walk. However, those improvements remained partial and fluctuating, sometimes allowing the symptom to return temporarily secondary to frustrations or annoyances. Finally, our patient relapsed. Nevertheless, his clinical state presently remains better than that in which we first knew him.
The treatment of conversion disorders has been the subject of few studies and predominantly remains symptomatic. Its main goals are: to lessen secondary gains impact by adopting a neutral behaviour towards the symptom and by encouraging physical rehabilitation; to lower the symptom by allowing the patient to understand the normal functioning of the diseased organ, and; to help the patient to deal with stressful situations. There is no evidence that hypnosis is superior to medical and other psychotherapeutic approaches. Pharmacological treatments may be helpful in the case of anxiety, impulsivity or depression, albeit delivered with caution. According to some case reports, transcranial magnetic stimulation has also been associated with clinical remission. Although the use of ECT in motor conversion disorders constitutes an uncommon procedure, and even if no clinical trial has evaluated its impact on such a pathological condition, several case reports suggest that electroconvulsive therapy can be efficient in the treatment of motor conversion disorders. This efficacy may rely on several hypotheses. ECT could induce neural modifications, and participate in the suppression of an active inhibition, which is responsible for hysterical symptoms. Indeed, conversion cerebral disorder correlates can be explored with the help of functional neuro-imaging techniques, which could therefore also identify ECT neural effects. ECT adverse effects on memory could lead to a new relationship with the symptom, and modulate the psychological conflict which has participated in its emergence. Narcoanalysis, ECT sessions could have an impact on consciousness by means of some dissolution and reorganization phenomenon. It could therefore participate in the ending of an emotional block, the psychic integration of traumatic events and the recovery of a voluntary motor control. Finally, ECT could be efficient thanks to its antidepressant properties, especially its ability to stimulate triaminergic, and particularly dopaminergic transmission. This case report reminds us how difficult it can be to deal with severe conversion disorders, and to navigate between two reefs, which are abstention, and therapeutic escalation.
Morphological and functional changes have been repeatedly reported in the brain organization of depressed patients. The main modifications demonstrated by structural magnetic resonance imaging (MRI) ...are a reduction in the gray matter volume within the prefrontal cortex, the hippocampus, and the striatum. The reduction in gray matter volume and the morphological atrophy are probably due to an excess of neural loss (apoptosis) and an altered regulation of the neurotrophic processes. Hence, a deficit in neurotrophic factor synthesis (brain-derived neurotrophic factor BDNF, neurotrophin NT-3, NT-4/5, Bcl-2, etc.) may be responsible for increased apoptosis in the hippocampus and prefrontal cortex corresponding to the cognitive impairment described in depression. This hypothesis seems to be confirmed by the decreased expression of neurotrophic factors (e.g., BDNF mRNA) in animal models of depression. In parallel, the neural plasticity (functional aspects of synaptic connectivity and long-term potential activity LTP) is decreased. However, the most interesting data concern the possible reversibility of this dysregulation with antidepressant treatment. For example, communication between the hippocampus and the prefrontal cortex could be re-established, enabling in a way the cognitive processes to be “reset.” From a clinical point of view, the consequences of such a phenomenon are manifold:
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apoptosis and neurotrophic deficits could explain most of the symptoms of depression depending on the regions concerned;
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the resulting alterations in neuroplasticity could explain the dysconnectivity found between the same regions;
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enhancing neurotrophic synthesis in those regions could not only stimulate synaptogenesis and reverse neural (dendritic) atrophy but could also play a positive role in LTP genesis which is crucial for re-establishing adapted communication.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Résumé Au cours de la dernière décennie, un très grand nombre de travaux de stimulation magnétique transcrânienne (ou transcranial magnetic stimulation , TMS) ont été effectués, comprenant notamment ...l’élaboration de nouveaux paradigmes de stimulation, l’intégration des données d’imagerie et le couplage de techniques de TMS et d’EEG ou de neuroimagerie. Aussi, devant l’accumulation de ces données difficiles à synthétiser, plusieurs sociétés savantes francophones ont mandaté un groupe d’experts français afin de réaliser une analyse exhaustive de la littérature concernant la TMS. Ce texte de consensus reprend l’ensemble des conclusions de ce groupe d’experts sur les mécanismes d’action, les règles de sécurité et les indications thérapeutiques de la TMS, notamment répétitive (rTMS). Des séances de TMS ont été réalisées chez des milliers de sujets sains ou des patients souffrant de diverses maladies neurologiques ou psychiatriques, permettant une meilleure évaluation des risques relatifs liés à cette technique. Le nombre d’effets secondaires rapportés est extrêmement faible, la complication la plus sérieuse étant la survenue de crises d’épilepsie. Dans la plupart des crises rapportées, les paramètres de stimulation ne suivaient pas les recommandations précédemment publiées (Wassermann, 1998) 430 et souvent il existait un traitement médicamenteux qui pouvait abaisser le seuil épileptogène. Les recommandations sur la sécurité d’utilisation de la TMS/rTMS ont été récemment actualisées (Rossi et al., 2009) 348 , fixant les contre-indications et établissant de nouvelles limites concernant les différents paramètres de stimulation. Concernant les règles de sécurité, les recommandations que nous proposons pour un public francophone sont donc en grande partie fondées sur ce précédent article avec quelques adaptations. La question des indications thérapeutiques de la rTMS n’avait jamais fait en revanche l’objet d’un travail de synthèse. Nous avons abordé les pathologies suivantes : douleurs chroniques, mouvements anormaux, accidents vasculaires cérébraux, épilepsie, acouphènes et pathologies psychiatriques. Il y a déjà pour certaines d’entre elles (douleurs neuropathiques chroniques, épisodes dépressifs majeurs, hallucinations auditives), un niveau de preuves suffisant des études publiées, pour retenir une indication thérapeutique de la rTMS en pratique clinique. Ces indications devraient encore se développer dans les prochaines années et les paramètres de stimulation optimaux à utiliser en fonction de ces indications devraient également se préciser.
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Abstract only
e20551
Background: Lung cancer is the leading cause of cancer mortality, with smoking the major risk factor
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. Advances in treatment (tx) are lengthening survivorship increasing the ...importance in smoking cessation among diagnosed pts. Barriers to counseling include: time, skill, patient motivation, prognosis and short survival
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. This study analyzed smoking status and cessation counseling in better prognosis aNSCLC patients (pts) defined as those who completed at least two lines of systemic therapy (2L). Methods: Using Inovalon’s MORE
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Registry
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claims data for July 2013–2014, pts with aNSCLC identified by ICD-9 codes and treated with chemotherapy (chemo) or targeted therapy (TT; erlotinib, ceritinib, afatinib, or crizotinib) were selected. Pts >18 years of age and treated with 1L therapy within 6 months of diagnosis and who completed 2L were eligible. Pts with small cell lung cancer or secondary malignancies, or pts enrolled in a trial, were ineligible. Smoking history was assessed based on ICD-9 codes (305.1, 649.0, 989.84, V15.82), cessation drug use (bupropion, varenicline, nicotine gum or patches), counseling procedure codes (99406, 99407, G0436, S9453). Results: Of 5,319 pts, 2,198 completed 2L; of those 241 (11%) received 1L TT and 1,957 (89%) 1L chemo. 1L TT had a higher proportion of females (66% vs. 52%, p<0.0001) and a lower smoking rate (33% vs. 58%, p<0.0001) compared to chemo. Cessation rates (counseling or drug) were 9% for 1L TT and 13% for 1L chemo. Conclusions: RWE assessment of smoking incidence and cessation counseling is feasible. Despite methodological limitations one third pts on 1L TT had smoking documentation. Evidence of smoking cessation was present in 12% of pts irrespective of 1L tx choice. Our findings warrant increased focus on smoking cessation in aNSCLC. Table: see text
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e20593
Background: The rapidly expanding arsenal of systemic therapies for aNSCLC warrants a better understanding of treatment sequencing. This study evaluated the benefits of sequence ...choice through time to discontinuation (TTD). Methods: Using Inovalon’s MORE
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Registry
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claims data for July 2013–2014, patients (pts) with aNSCLC identified by ICD-9 codes and treated with chemotherapy (chemo) or targeted therapy (TT; erlotinib, ceritinib, afatinib, or crizotinib) were selected. Pts >18 years of age and treated with first-line (1L) therapy within 6 months of diagnosis were eligible. Pts with small cell lung cancer or secondary malignancies, or pts enrolled in a trial, were ineligible. TTD (time from 1L start to 2L stop + 90 days, or switch to 3L were analyzed by sequence group: chemo-to-chemo (A), chemo-to-TT (B), TT-to-chemo (C), and TT-to-TT (D). All-cause TTD was assessed using Kaplan–Meier curves. Pt characteristics were assessed using descriptive statistics. Results: Of 5,319 pts, 567 (11%) received 1L TT and 4,752 (89%) received 1L chemo; 2,198 pts (41%) progressed to 2L. Significant differences were noted between groups (table). Group D had the most women and longest mean follow-up time and TTD. Group C had the lowest mean age and greatest proportion of 3L pts. Group B had the highest mutation testing rate and second longest mean TTD. Conclusions: The positive impact of precision medicine on TTD is striking. The fact that chemo following 1L TT resulted in the lowest TTD calls this strategy into question. Research is warranted to address the continued role of salvage chemo in TT eligible aNSCLC. Table: see text
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