Left atrial appendage occlusion in patients suffering from advanced chronic kidney disease (stage 4 and 5). Long-term follow-up.

INTRODUCTION AND OBJECTIVES: Advanced chronic kidney disease (A-CKD) combined with atrial fibrillation increases the risk of both thrombogenic and bleeding events. Left atrial appendage occlusion (LAAO) may be an alternative to oral anticoagulation to prevent thromboembolic events. We aimed to evaluate the outcomes of LAAO in patients with A-CKD. METHODS: Comparison at long-term follow-up of patients diagnosed with and without A-CKD (eGFR<30 mL/min/1.73 m2 ) who underwent LAAO between 2009 and May 2022. RESULTS: Five hundred seventy-three patients were included. Eighty-one (14%) were diagnosed with A-CKD. There were no differences in sex, age, and cardiovascular risk factors, except for diabetes which was more frequent in patients with A-CKD. The control group had higher rates of stroke, both ischemic and hemorrhagic. There were no differences in the CHA2 DS2 -VASc score, although A-CKD patients had a higher bleeding risk according to the HASBLED scale. Global procedural success was 99.1%. At follow-up, there were no differences in stroke rate: at 1-year (HR: 1.22, IC-95%: 0.14-10.42, p = 0.861); at 5-years (HR: 0.60, IC-95%: 0.08-4.58, p = 0.594). Although bleeding events were higher in the A-CKD group, no differences were found in major bleeding (defined BARC ≥ 3) at 1-year (HR: 1.34, IC-95%: 0.63-2.88, p = 0.464) or at 5-years follow-up (HR: 1.30, IC-95%: 0.69-2.48, p = 0.434). Mortality rate at 5 years was higher in the A-CKD patients (HR: 1.84, IC-95%: 1.18-2.87, p = 0.012). CONCLUSIONS: LAAO is an effective and safe treatment in A-CKD patients to prevent ischemic events and bleeding. This strategy could be an alternative to oral anticoagulation in this high-risk group of patients.

COVID-19 lockdown and the rate of central precocious puberty.

PURPOSE: The aim of our study was to compare the incidence of idiopathic central precocious puberty (CPP) in our highly specialized Endocrinological Center before and after the onset of COVID-19 lockdown; we also aimed to identify any potential difference between girls with CPP from the two different time periods. METHODS: We retrospectively analyzed the auxological profile of 49 girls with idiopathic CPP: 30 with pre-lockdown onset and 19 with post-lockdown onset of the disease. We collected patients' characteristics (medical history, physical examination, baseline and dynamic hormonal assessment, bone age, pelvic ultrasound) and compared them between the two groups. RESULTS: We registered an almost threefold increase in CPP incidence in the 2020-2021 period compared to the previous six years. In post-lockdown patients we found a trend for an earlier diagnosis in terms of both chronological age (p 0.0866) and days between the onset of first pubertal signs and diagnosis (p 0.0618). We also found that post-lockdown patients had a significantly lower hypothalamus-pituitary-gonadal axis activation (lower ∆LH% after GnRH test, p 0.0497), a significantly lower increase in bone age calculated at RUS with TW3 method (p 0.0438) and a significantly reduced ovarian activation in females (lower delta-4-androstenedione levels, p 0.0115). Interestingly, post-lockdown patients were born from mothers with an older age at menarche (p 0.0039). CONCLUSIONS: Besides confirming a significant increase in new diagnoses of CPP in the post-lockdown period, our findings among Post-lockdown girls also suggest a less progressive form of CPP and a stronger environmental influence compared to genetic background in determining the timing of pubertal onset.

Mental health in adolescents with obesity: conflicting views among physicians, a qualitative study.

Mental health issues in adolescents with obesity are multifold, with no explicit screening recommendations. The aim of this research is to explore how this screening is performed by physicians and, thus, how it impacts adolescents' care pathways, offering insights into how to improve it through a qualitative study using interpretative phenomenological analysis. Twenty physicians (non-psychiatrist physicians and child and adolescent psychiatrists) involved at various stages in the care pathway were interviewed with semi-structured questionnaires. The findings connect 2 meta-themes. Non-psychiatrist physicians perceive widespread but ill-defined suffering in adolescents with obesity. Non-psychiatrist physicians see screening for mental conditions as mandatory. Unlike child and adolescent psychiatrists, they are not experts in distinguishing psychosocial suffering from psychiatric disorders. Screening is clinical. Adolescents' demand to lose weight in a context of shaming and alexithymia limits their access to psychiatric care. Child and adolescent psychiatrists then redefine the medical response to polymorphous symptoms. Psychiatric diagnoses mainly involve anxiety and depression symptoms, seldom eating disorders.    Conclusion: Physicians have overtly conflicting perspectives over the intensity of mental conditions. Non-psychiatrists, sensitive to perceived distress, seek to have it quickly appraised if they detect a significant suffering. Child and adolescent psychiatrists find appraisal complex to perform in the absence of means, interest, and/or experience. Improving screening requires training health professionals and using multidisciplinary assessment means. What is Known: • Mental health and eating disorders are contributing factors of obesity but their relationship remains complex between cause and consequence. • Mental health conditions and psychosocial suffering are the main complications among adolescents suffering from obesity with guilt, sadness, or stigma. What is New: • Non-psychiatric physicians express their need of a specialized diagnosis to define this suffering, but the lack of availability of psychiatrists and the necessity of time and of a multidisciplinary team lead to a delayed assessment. • For psychiatrists, this suffering is often not a psychiatric condition. Though requiring attention, this can lead to a misunderstanding between professionals.

Root phosphoenolpyruvate carboxylase activity is essential for Sorghum bicolor tolerance to ammonium nutrition.

Phosphoenolpyruvate carboxylase (PEPC; EC 4.1.1.31) is an enzyme family with pivotal roles in plant carbon and nitrogen metabolism. A main role for non-photosynthetic PEPC is as anaplerotic enzyme to load tricarboxylic acid (TCA) cycle with carbon skeletons that compensate the intermediates diverted for biomolecule synthesis such as amino acids. When plants are grown under ammonium (NH4+) nutrition, the excessive uptake of NH4+ often provokes a stress situation. When plants face NH4+ stress, N assimilation is greatly induced and thus, requires the supply of carbon skeletons coming from TCA cycle. In this work, we addressed the importance of root PEPC and TCA cycle for sorghum (Sorghum bicolor L. Moench), a C4 cereal crop, grown under ammonium nutrition. To do so, we used RNAi sorghum lines that display a decrease expression of SbPPC3 (Ppc3 lines), the main root PEPC isoform, and reduced root PEPC activity. SbPPC3 silencing provoked ammonium hypersensitivity, meaning lower biomass accumulation in Ppc3 respect to WT plants when growing under ammonium nutrition. The silenced plants presented a deregulation of primary metabolism as highlighted by the accumulation of NH4+ in the root and the alteration of normal TCA functioning, which was evidenced by the accumulation of organic acids in the root under ammonium nutrition. Altogether, our work evidences the importance of non-photosynthetic PEPC, and root TCA cycle, in sorghum to deal with high external NH4+ availability.

Geometrical Frustration, Correlated Disorder, and Emerging Order in a Corrugated C_{60} Monolayer.

Under certain experimental conditions, the deposition of C_{60} molecules onto an atomically flat copper surface gives rise to the formation of corrugated islands. This corrugation, which reflects a molecular displacement perpendicular to the surface plane, presents an astonishing pattern: It is well described by a frustrated Ising spin Hamiltonian whose thermodynamics is compatible with a spin liquid about to transit toward an ordered zigzag state. Here we study the statistical properties of such a molecular corrugation using a structure factor analysis, a tool generally employed in frustrated magnetism. More specifically, the real and reciprocal space analysis of pairwise molecule correlations allows us to demonstrate that the C_{60}/Cu system, in which magnetism is totally absent, has all the characteristics of a triangular Ising antiferromagnet. Our results indicate that the organization of two-dimensional matter, at the molecular length scale, sometimes turns out to be particularly close to that encountered in highly frustrated magnets.

Inpatient management of diabetes and hyperglycaemia: an audit of Spanish hospitals.

OBJECTIVES: Evaluation of quality of care for patients with diabetes mellitus admitted to hospitals in Spain. METHODS: Cross-sectional study in one day that included 1193 (26.7%) patients with type 2 diabetes or hyperglycaemia out of a total of 4468 patients admitted to the internal medicine departments of 53 hospitals in Spain. We collected demographic data, adequacy of capillary glycaemic monitoring, treatment administered during admission, and recommended therapy at discharge. RESULTS: The median age of the patients was 80 years [74-87], of which 561 (47%) were women, with a Charlson index of 4 points [2-6], and 742 (65%) were fragile. Median blood glucose on admission was 155 mg/dl [119-213]. On the third day, the number of capillary blood glucose levels in target (80-180 mg/dl) at pre-breakfast was 792/1126 (70.3%), pre-lunch 601/1083 (55.4%), pre-dinner 591/1073 (55.0%), and at night 317/529 (59.9%). A total of 35 patients (0.9%) were suffering from hypoglycemia. Treatment during hospitalization was performed with sliding scale insulin in 352 (40.5%) patients, with basal insulin and rapid insulin analogues in 434 (50%), or with diet exclusively in 101 (9.1%). A total of 735 (61.6%) patients had a recent HbA1c value. At discharge, the use of SGLT2i increased significantly (30.1% vs. 21.6%; p < 0.001), as did the use of basal insulin (25.3% vs. 10.1%; p < 0.001). CONCLUSIONS: There is an excessive use of sliding scale insulin as well as insufficient information on HbA1c values and prescription upon discharge of treatments with cardiovascular benefit.

[Mobile child psychiatric team in French Guiana: Analyzing Amerindian teenager issues]. / Équipe mobile de pédopsychiatrie en territoire guyanais : questionnement de l'adolescent amérindien.

INTRODUCTION: Since their French naturalization in 1969, Amerindians of French Guiana have been facing a full and fast reorganization of their way of life. Teenagers, at the forefront of this cultural transition, are challenging French school institutions, as well as cultural society and care system organizations in Amazonian French remote villages. Rates of autolytic behaviors such as toxic substance abuse or suicide attempts, but mostly completed suicides, are alarming among this adolescent population. To improve care delivery to those teenagers, a mobile child psychiatric team was implemented in 2013. METHODS: We describe this device, its activities and the problematics encountered. RESULTS: This team's purpose is to lead a psychiatric evaluation of teenagers in order to determine a possible psychiatric diagnosis and elaborate a care plan. Although the results are mostly encouraging, this device seems to show some limitations: lack of time dedicated to these interventions, lack of psychiatric care available for follow-up in these villages, tremendous numbers of social distress situations implicated in psychological issues. Moreover, it appears that cultural aspects must be considered in the analysis of the Amerindian adolescent population's issues and the determination of providing care. CONCLUSION: Implementation of actions based on more educational and social levels might be a solution.

The experience of healthcare professionals treating adolescents with eating disorders in psychiatric and pediatric inpatient units for adolescents: A qualitative study.

OBJECTIVES: The recommended treatment for Eating Disorders (EDs) is multidisciplinary and multimodal. Nonetheless, the complex linkage of the different disciplines involved is not necessarily simple. We analyzed the experience of healthcare professionals faced with psychiatric and psychological symptoms in adolescents with EDs in two "multidisciplinary" inpatient units embedded predominantly in different paradigms - one pediatric and one psychiatric. METHODS: Qualitative analysis of 20 healthcare staff members' interviews from different professional backgrounds working in inpatient units for EDs in Montreal (Canada) and Paris (France). RESULTS: The "Complex patients" theme discusses the need for a global approach to the multiplicity of symptoms presented by these patients. "Management and its limits" describes the daily management of psychiatric symptoms in both units. "Psychiatry and Adolescent medicine: from opposition to collaboration" describes the different levels at which these disciplines work together and how this cooperation may be evolving. CONCLUSIONS: The complex entanglement intrinsic in EDs of the patients' somatic, psychosocial, psychiatric, and adolescent problems requires collaboration between disciplines, but the modalities of this collaboration are multiple and evolve non-linearly in specialized treatment units. A multilevel approach must be offered, with the degree of collaboration (multidisciplinary, interdisciplinary and transdisciplinary) appropriate to the complexity of each adolescent's issues.

[From the laboratory to the clinic in acute ischaemic stroke. In vitro and in vivo experimental models]. / Del laboratorio a la clínica en el ictus isquémico agudo. Modelos experimentales in vitro e in vivo.

INTRODUCTION: Cerebrovascular disease is one of the leading causes of death, disability and dementia around the world. For the most common form of the disease, ischaemic stroke, there is only one drug available, tissue plasminogen activator, and few patients can benefit from this therapy because of the strict inclusion criteria established for its use. This circumstance makes it crucial to search for new forms of treatment to combat the sequelae of the disease, and this requires the development of new biomimetic models that allow for a better understanding of its evolution. DEVELOPMENT: In this review, we update the platforms and models most widely used in recent years to study the pathophysiology of ischaemic stroke. On the one hand, we review the two- and three-dimensional platforms on which in vitro assays are carried out and, on the other, we describe the most commonly used in vivo experimental models and techniques for assessing ischaemic damage. CONCLUSIONS: The ultimate aim of developing good experimental models is to find new forms of treatment and thus improve patients' prognosis and quality of life. It is therefore important to generate new in vitro devices and to further refine in vivo models to enable a good clinical translation.

TITLE: Del laboratorio a la clínica en el ictus isquémico agudo. Modelos experimentales in vitro e in vivo.Introducción. La enfermedad cerebrovascular es una de las principales causas de muerte, discapacidad y demencia en el mundo. La forma más frecuente de la enfermedad, el ictus isquémico, sólo tiene un fármaco disponible, el activador tisular del plasminógeno, y pocos pacientes pueden beneficiarse de esta terapia por los estrictos criterios de inclusión establecidos para su uso. Esta circunstancia hace crucial la búsqueda de nuevas formas de tratamiento para combatir las secuelas de la enfermedad, y para ello es necesario el desarrollo de nuevos modelos biomiméticos que permitan conocer mejor su evolución. Desarrollo. En esta revisión, actualizamos las plataformas y modelos más utilizados en los últimos años para estudiar la fisiopatología del ictus isquémico. Por un lado, repasamos las plataformas bi- y tridimensionales sobre las que se llevan a cabo los ensayos in vitro y, por otro lado, describimos los modelos experimentales in vivo más utilizados en la actualidad, así como las técnicas para evaluar el daño isquémico. Conclusiones. El desarrollo de buenos modelos experimentales tiene como fin último encontrar nuevas formas de tratamiento y, de esta manera, mejorar el pronóstico y la calidad de vida de los pacientes; por ello, es importante generar nuevos dispositivos in vitro y refinar más aún los modelos in vivo para hacer posible una buena traslación a la clínica.

[Female patients with eating disorders and their parents experience in China: A qualitative study]. / Vécu de jeunes femmes présentant un trouble des conduites alimentaires et de leurs parents en Chine : étude qualitative.

INTRODUCTION: Recent tendencies show a stabilization in Western countries of the incidence of anorexia nervosa but an increase in Asian countries where it used to be lower. The emergence of these diseases in non-Western countries suggests a culture change syndrome on an individual or societal scale. The great number of changes having occurred in China in the past decades would favor the occurrence of eating disorders. A variability of symptoms of eating disorders can be observed depending on the cultural background which also influences the treatment. There are few studies that exist within an Asian context, and they mostly focus on the care. OBJECTIVES: In this study, we intend to explore the experience of Chinese female patients hospitalized for an eating disorder and the experience of their parents: their relationship with the symptoms, with their health and their understanding of the disease, in order to identify the impact of the Chinese cultural context upon the disorder. METHOD: It is an observational, phenomenological and qualitative study. A purposive sampling was formed from a clinical population group of young teenagers and women, coming from various areas of China and hospitalized in the specialized Psychosomatic Department of Shanghai Mental Health Center, in August and December 2017. The degree of urbanization, the regions and ages categories were wide-ranging, allowing us to maximize the richness of the data assessing the disease and care representations. Two semi-structured interviews were realized with the participants, then with one or both parents. The interviews were realized with an evaluative interview guide by the same researcher together with a Chinese psychology student in order to clarify the translation and the interpretation of the cultural elements expressed by the participants. The analysis was based on the Interpretative Phenomenological Analysis. Two researchers read the interview transcripts several times, identified themes then connections between the themes to build a set of meta-themes depicting the narratives. Every meta-theme was linked with its corresponding themes which necessitated during the analysis constant back and forth between the analytical data and the source material. RESULTS: Thirteen female patients and 11 parents took part in the study. The patients were between 12 and 31 years of age. They showed a wide range of eating disorders: restrictive anorexia, anorexia nervosa, or bulimia nervosa. Their Body Mass Index at the time of the interview ranged from 11 to 22. Three meta-themes emerged from the analysis: concerns about thinness and health are real catalysts for seeking care, the opposition between parental beliefs about factors of good health and eating symptoms in young girls, and changes in parenting and traditional educational methods induced by eating symptoms. These different themes highlight the fear of thinness and good health being powerful therapeutic levers in China, the intergenerational agreements and disagreements on the factors of good health with the parental experience of consideration around the eating disorder of their daughter, and an impact of traditional educational modalities on the family relational aspects that change with the disorder. DISCUSSION: Exploring the experience of young Chinese girls or women suffering from eating disorders highlights the complex interactions between the cultural and clinical context of eating disorders. Weight loss is experienced with great difficulty by the young women of our study, who report somatic symptoms and worry about their thinness. Our results show the central position occupied by maintaining oneself in good health in China, for parents and teenagers alike. This allows a quick reliance on healthcare. The intergenerational differences in China are increased by the rapid changes occurring within Chinese society which can cause conflicts and particularly violent struggles. Its younger generations are becoming more and more globalized. These results provide further evidence that eating disorders are culture change syndromes. The therapeutic impact of our results is twofold. On the individual level, there are therapeutic cultural levers linked with Chinese culture, and they have to be sought in all cultures. The therapeutic education of Chinese patients must be centered on the somatic consequences of the disease in order to increase the adherence to the care. On the familial level, the therapeutic approaches centered on intergenerational conflicts must be developed. CONCLUSION: The rapid sociocultural changes in China are causing important intergenerational differences, notably between traditional educational modalities and the need for independence of young people who require specific familial therapy. The cultural elements must be taken into account in order to understand eating disorders and to develop relevant therapeutic approaches.

[Qualitative study of parents' experience after their teen's suicide attempt]. / Étude qualitative de l'expérience des parents après la tentative de suicide de leur adolescent.

INTRODUCTION: Suicidal attempts are frequent during adolescence and concern the whole family, particularly parents whose role is crucial in provision of therapeutic support. Yet very few studies have been performed bearing on their lived experience. In this study, we will analyze the experience of parents after the suicidal attempt of their adolescent. PARTICIPANTS & METHODS: Qualitative study based on semi-structured interviews of 13 parents of teenagers followed in child and adolescent psychiatry for suicidal behavior. Interview included 5 to 6 open and conversational questions. We analyzed interviews, after transcription, using the Interpretative Phenomenological Analysis approach. RESULTS: The parents' wellness and behavior are directly affected by their child's mental status. When they are informed of the suicidal attempt, they feel very deep sadness, in a form of initial distress which is part of the grieving process regarding their image of idealized parents. They feel anger against the teenager, their anger is also directed against family members and close friends as well as against caregivers. Given the uncertainty, they doubt their own educative and empathetic competences, and lack confidence in their capacity for providing help. They express their need for help and support with regard to understanding their child's suicidal attempt, with regard to the emotional turmoil they experience and in reinforcing their competencies as carers. CONCLUSION: It appears that parents are extremely touched by their teenager suicidal attempt. They need a personal follow up, including familial medical care but also a personal space of support. Parents group, as well as psycho educative intervention, are also welcomed to give efficient method to lift their child.

Severe nondiabetic plantar mal perforant in an adolescent girl with anorexia nervosa.

PURPOSE: We describe the case of a severe skin ulcer of the heel in an adolescent girl hospitalised for anorexia nervosa (AN) associated with a severe excessive exercise. METHODS: This case report includes retrospective anamnestic and clinical data from the patient's medical record. A literature review was conducted on the dermatological changes described in AN. CONCLUSION: Severe starving syndrome in AN due to intake restriction and pathological associated behaviours can cause serious somatic complications, including psycho-dermatological lesions. We describe a rare case of a nondiabetic plantar "mal perforant" resulting from multiple risk factors including prolonged undernutrition, excessive exercise, and significant psychiatric comorbidity with self-injury. We suggest that, in this context, one should include a particular attention to the risk of non-visible skin complications reflecting both the AN symptoms severity and the severity of the patient's psychological distress requiring individualised and specialised multidisciplinary approach. LEVEL OF EVIDENCE: Level V, case report.