Emergency psychiatric management of borderline personality disorder: Towards an articulation of modalities for personalised integrative care.

Building on existing literature, the authors draw the landscape of psychiatric emergencies, and focus on borderline personality disorder, frequently encountered, and strongly linked to death by suicide. A review of knowledge in terms of diagnosis, prognosis, etiology, and treatment, as well as their own experiences, lead them to propose areas of progress that would secure the patient's care pathway. The evolution of society has led psychiatric emergency departments to play the role of a safety net and an entry point to the mental health system. Borderline personality disorder is one of the most common pathologies encountered in psychiatric emergencies. It represents a major concern, long characterized by an often dramatic evolution, and by the human and economic stress it generates. However, since the 1990s, knowledge of this disorder has been refined, and today there are various means of evaluation, good clinical practices and psychotherapeutic treatments, thanks to which significant and lasting improvement is possible. Recent studies highlight the crucial role of hospital caregivers, and the benefit of consolidating their skills by providing them with the knowledge and tools specific to this disorder. They also converge on the interest of setting up specific emergency treatment modalities, particularly highly structured, safe and empowering for the patient, in order to improve their effectiveness. The authors suggest that a case formulation model for persons with borderline personality disorder in emergency would make it possible to activate these two levers of progress, while improving collaboration between hospital and outpatient care. This would also address their main concern of optimizing the patient's therapeutic pathway and reinforcing adherence to treatment that could bring remission, and should be supported by data from empirical research.

Heterografting with nonself rootstocks induces genes involved in stress responses at the graft interface when compared with autografted controls.

Although grafting is widely used in the agriculture of fruit-bearing crops, little is known about graft union formation in particular when two different species are grafted together. It is fascinating that two different plant species brought together can develop harmoniously as one organism for many decades. The objective of this study was to determine whether grafting two different grapevine genotypes alters gene expression at the graft interface in comparison to the presumably wound-like gene expression changes induced in autografts. Gene expression at the graft interface was studied 3, 7, 14, and 28 d after grafting in hetero- and autografts of grapevine (Vitis spp.). Genes differentially expressed between the hetero- and autografts during graft union formation were identified. These genes were clustered according to their expression profile over the time course. MapMan and Gene Ontology enrichment analysis revealed the coordinated upregulation of genes from numerous functional categories related to stress responses in the hetero- compared to the autografts. This indicates that heterografting with nonself rootstocks upregulates stress responses at the graft interface, potentially suggesting that the cells of the graft interface can detect the presence of a nonself grafting partner.

An attempt to validate the modification of the American-European consensus definition of acute lung injury/acute respiratory distress syndrome by the Berlin definition in a university hospital.

PURPOSE: The Berlin definition for acute respiratory distress syndrome (ARDS) is a new proposal for changing the American-European consensus definition but has not been assessed prospectively as yet. In the present study, we aimed to determine (1) the prevalence and incidence of ARDS with both definitions, and (2) the initial characteristics of patients with ARDS and 28-day mortality with the Berlin definition. METHODS: We performed a 6-month prospective observational study in the ten adult ICUs affiliated to the Public University Hospital in Lyon, France, from March to September 2012. Patients under invasive or noninvasive mechanical ventilation, with PaO2/FiO2 <300 mmHg regardless of the positive end-expiratory pressure (PEEP) level, and acute onset of new or increased bilateral infiltrates or opacities on chest X-ray were screened from ICU admission up to discharge. Patients with cardiogenic pulmonary edema were excluded. Patients were further classified into specific categories by using the American-European Consensus Conference and the Berlin definition criteria. The complete data set was measured at the time of inclusion. Patient outcome was measured at day 28 after inclusion. RESULTS: During the study period 3,504 patients were admitted and 278 fulfilled the American-European Consensus Conference criteria. Among them, 18 (6.5 %) did not comply with the Berlin criterion PEEP ≥ 5 cmH2O and 20 (7.2 %) had PaO2/FiO2 ratio ≤200 while on noninvasive ventilation. By using the Berlin definition in the remaining 240 patients (n = 42 mild, n = 123 moderate, n = 75 severe), the overall prevalence was 6.85 % and it was 1.20, 3.51, and 2.14 % for mild, moderate, and severe ARDS, respectively (P > 0.05 between the three groups). The incidence of ARDS amounted to 32 per 100,000 population per year, with values for mild, moderate, and severe ARDS of 5.6, 16.3, and 10 per 100,000 population per year, respectively (P < 0.05 between the three groups). The 28-day mortality was 35.0 %. It amounted to 30.9 % in mild, 27.9 % in moderate, and 49.3 % in severe categories (P < 0.01 between mild or moderate and severe, P = 0.70 between mild and moderate). In the Cox proportional hazard regression analysis ARDS stage was not significantly associated with patient death at day 28. CONCLUSIONS: The present study did not validate the Berlin definition of ARDS. Neither the stratification by severity nor the PaO2/FiO2 at study entry was independently associated with mortality.

Prospective observational study of the non-invasive assessment of immediate postoperative pain using the analgesia/nociception index (ANI).

BACKGROUND: The analgesia/nociception index (ANI), a 0-100 non-invasive index calculated from heart rate variability, reflects the analgesia/nociception balance during general anaesthesia. The aim of this study was to evaluate the ANI in the assessment of immediate postoperative pain in adult patients undergoing general anaesthesia. METHODS: Two-hundred patients undergoing scheduled surgery or endoscopy with general anaesthesia were included in this prospective observational study. Pain intensity was assessed using a 0-10 numerical rating scale (NRS) after arousal from general anaesthesia. Receiver-operating characteristic (ROC) curves were built to assess the performance of ANI to detect patients with NRS>3 and NRS ≥ 7 on arrival in the postoperative care unit. RESULTS: A negative linear relationship was observed between ANI and NRS (ANI=-5.2 × NRS+77.9, r(2)=0.41, P<0.05). At the threshold of 57, the sensitivity and specificity of ANI to detect patients with NRS>3 were 78 and 80%, respectively, with a negative predictive value of 88%, corresponding to an area under the ROC curve (AUC) of 0.86. At the threshold of 48, the sensitivity and specificity of ANI to detect NRS ≥ 7 were 92 and 82%, respectively, with a negative predictive value of 99%, corresponding to a ROC curve AUC of 0.91. CONCLUSIONS: A measurement of ANI during the immediate postoperative period is significantly correlated with pain intensity. The measurement of ANI appears to be a simple and non-invasive method to assess immediate postoperative analgesia.

[Awake intubation using Pentax Airway Scope as an alternative to awake fiberoptic intubation in management of anticipated difficult tracheal intubation in major burn patients]. / Le glottiscope AWS-Pentax™, alternative à la fibroscopie dans deux cas d'intubation difficile prévue du brûlé grave.

Intubating patients with facial burn is difficult to most anesthesiologists. Awake flexible fiberoptic intubation is the gold standard for management of anticipated difficult tracheal intubation. However, serious facial burn and dysmorphic syndrome can make fiberoptic intubation more difficult or impossible. We report the use of awake oral intubation using the Pentax-Airway Scope (AWS) in two major burn patients with facial injury, in whom awake fiberoptic intubation was impossible. As shown in morbidly obese patient and in patients with unstable necks, AWS could be useful to facilitate tracheal intubation in awake, facial burn patients presenting with a potentially difficult airway. Awake AWS intubation seems as a potential alternative to awake fiberoptic intubation.

Comparison of transesophageal and transthoracic contrast echocardiography for detection of an intrapulmonary shunt in liver disease.

STUDY OBJECTIVES: Contrast transthoracic echocardiography (TTE) is currently used to identify intrapulmonary shunt (IPS) in patients with end-stage liver disease. The aim of this study was to compare the use of contrast TTE and transesophageal echocardiography (TEE) in detecting IPS. DESIGN: Thirty-seven consecutive outpatients with severe liver disease awaiting liver transplantation underwent contrast TEE and TTE. The IPS was assessed semiquantitatively in four grades with TEE and as positive or negative with TTE. SETTING: ICU. INTERVENTIONS: Patients underwent contrast TEE after pharyngeal anesthesia alone followed by contrast TTE. Contrast echocardiography was performed with a modified fluid gelatin solution. RESULTS: Overall detection rate of an IPS was 51% with TEE and 32% with TTE (p < 0.001). Four patients had an IPS detected with TEE but not with TTE. Quality of imaging was poor in 22% with TTE and 0% with TEE (p < 0.001). A PaO2 < 80 mm Hg or a dyspnea was associated with an IPS in 56% and 50% of patients with TEE and in 33% and 25% with TTE, respectively. CONCLUSION: Contrast-enhanced TEE is superior to TTE for detecting an IPS in patients with severe liver disease awaiting liver transplantation. The use of gelatin contrast solution allows an early detection of IPS. Because of the high sensitivity of TEE, all patients suspected of hepatopulmonary syndrome should undergo TEE in search of an IPS if TTE is normal.

[Prevention of arterial hypotension during spinal anesthesia using intramuscular ephedrine in older people]. / Prévention de l'hypotension artérielle au cours de la rachianesthésie par l'éphédrine intramusculaire chez la personne âgée.

OBJECTIVE: To assess the efficacy of intramuscular ephedrine for prevention of hypotension following subarachnoid block (SB) in the elderly. STUDY DESIGN: Prospective, randomized double blind study vs placebo. PATIENTS: Twenty patients, aged 60 years or more, of physical class ASA 2 or 3, scheduled for surgical fixation of fractured neck of femur under SB, allocated into two groups of ten each. METHODS: After oral premedication with hydroxyzine 50 mg, 90 min before surgery, and preloading with cristalloid solution 10 mL.kg-1, the subarachnoid space was punctured with the patient in lateral position using a 22 Gauge spinal needle at the L3-L4 or L4-L5 interspace. Patients were given 0.5% hyperbaric bupivacaine intrathecally, according to body weight. Patients in ephedrine group received intramuscular ephedrine 30 mg immediately after SB. Patients in placebo group received 1 mL of intramuscular saline immediately after SB. When blood pressure decreased below 100 mmHg repeated bolus of ephedrine 6 mg were given intravenously. RESULTS: Patients in both groups experienced a significant decrease in systolic pressure after SB, the decrease being significantly greater in the placebo group. CONCLUSION: Prophylactic intramuscular ephedrine is effective to prevent hypotension associated with SB in the elderly.

Ultrastructural changes in superior vestibular commissural neurons following vestibular neurectomy in the cat.

The ultrastructural changes of the feline superior vestibular commissural neurons (CNs) were quantitatively assessed 8 weeks following ipsilateral vestibular neurectomy. Results indicated a slight degeneration of synaptic profiles (SPs; 25%) representing the primary vestibular afferent input onto CN soma. The synaptic vesicles of the remaining SPs, which likely originate from the cerebellum and the contralateral CNs, were smaller and rounder, suggesting a transition from an inhibitory to an excitatory mode of response. The SP loss had little impact on the CNs' capacity for protein synthesis and structural maintenance, since there was no change in the volume fraction of intracellular organelles. These data suggest that CNs do not degenerate and are likely functional after vestibular compensation. These findings support the role of the commissural pathway in vestibular compensation as proposed by Galiana et al, which is based on the assumption that the intervestibular commissural connections remain intact following vestibular neurectomy.

[Tooth injuries during general anesthesia, oral endoscopy and vibro-massage]. / Les traumatismes dentaires lors des anesthésies générales, des endoscopies orales et des sismothérapies.

It is generally recognized that dental injury during and after tracheal intubation is a significant problem. Damage may occur during oro-tracheal intubation, oral endoscopy or seismotherapy. The incidence was reported in a study conducted in the contentious department of Lyon hospitals, in France, from 1978 to 1988. Results confirm that damage is relatively common and that the majority of damaged teeth (67%) were known to have been previously restored, or weakened through periodontal disease prior to the damage occurring. Maxillary incisors were the most frequently injured teeth. Fracture of crowns and roots of natural teeth (44,8%), followed by partial luxation (20,8%) and avulsion (20,8%) were the most common injury. Several cases are presented which reveal the clinical value of dental damages that occur during orotracheal intubation, oral endoscopy or seismotherapy. Besides dental or gingival complications can appear immediately but also after a few days or weeks. Some of the most recent development in dental therapy such as the butterfly bridge, titanium implants and porcelain laminate veneers are described. Tooth protective guards must be put into widespread use. Legal implications of dental lesions occurring during oro-tracheal intubation, oral endoscopy or seismotherapy are presented.

Low frequency hearing threshold determination in newborns, infants and mentally retarded children by middle latency responses.

Middle latency (10-50 ms) responses (MLR) evoked by tone-pips (1,000 Hz 500 Hz) and early (0-10 ms) auditory evoked potentials (EAEP) evoked by chicks were recorded on 68 newborn babies (premature or at term), infants and children, some with central nervous system or psychiatric disorders, who had normal or impaired hearing. MLR were obtained either during sleep, chloral-hydrate sedation or ketamine anesthesia. Thresholds estimated from MLR and EAEP were compared to those from subsequent psychoacoustic pure tone testing. We confirm that MLR provide good threshold estimates for hearing in the low frequency range, whereas click evoked EAEP are good threshold indicators only for high frequencies.

[Tooth injuries during intubation: a new preventive device]. / Traumatismes dentaires au cours de l'intubation: un nouveau dispositif de prévention.

This study analyses 126 cases of dental injuries occurring during endotracheal intubation, reported to the service of litigations of the hospitals in Lyon over a ten-year period, and giving rise to a complaint. The overall rate was 1 out of 4,000 cases of intubation. The true incidence may be greater. As expected, the upper jaw teeth are most often involved, especially the left incisors. Among them 24.3% of the involved teeth were normal. Dental fractures were the most common lesion, together with total or partial dislocations. A questionnaire was sent to 534 anaesthetists to assess the main difficulties which they encounter when carrying out endotracheal intubation. The results of this enquiry demonstrated that anaesthetists were very aware of dental risks when carrying out intubation, and that there was a lack of efficient protective measures. Among them 81.2% claimed they would use a protective device from time to time, and 17.4% routinely, if one were available. Therefore we designed such a device. It is gutter-shaped, made with two different plastics, the more rigid one being on the outside. It fits over the upper jaw teeth. There is an indentation in the front, to check whether the device is placed correctly. The inner surface is made of foam which dulls the pressure which may be exerted on the device during intubation. This device was tested in 108 patients. Intubation was easy with the device in place in 73.2% of patients; mouth opening was reduced by a mean of 4.2 +/- 0.5 mm. The device made intubation more difficult, and even impossible, in patients whose mouth opened no more than 3.5 cm.(ABSTRACT TRUNCATED AT 250 WORDS)

[High frequency jet-ventilation in esophagotracheal fistula]. / Jet-ventilation à haute fréquence au cours d'une fistule oesotrachéale.

High-frequency jet-ventilation (HFJV) is not widely used, mainly because of technical problems and difficulty to assess its efficiency. However, there is general agreement on following major indication: artificial ventilation in patients with oesotracheal fistula. In the case reported here, HFJV allowed efficient ventilatory support through an endotracheal tube with deflated cuff. Weaning was progressively obtained. Surgery and postoperative course were uneventful.

[Per- and postoperative buprenorphine analgesia: cardiocirculatory and respiratory effects]. / L'analgésie per et postopératoire à la buprénorphine: effets cardio-circulatoires et respiratoires.

In 25 non-premedicated patients, buprénorphine (5 micrograms/kg - 1) has been injected i.v. 30 mn before coelioscopic sterilization under general anaesthesia. Following the i.v. injection there no significant modification of the arterial systolic and diastolic blood pressure was observed but post-operative bradycardia. Tidal volume and minute/ventilation decreased whereas the respiratory rate remained stable. Arterial blood gaz analysis showed slightly hypoxaemia and a significant rise of PaCO2 with post-operative acidosis similar to that in the control group. Good postoperative analgesia was achieved but with profound sedation and a high incidence of nausea and vomiting.