Treating strangeness: Medicine and human dignity at the time of COVID-19.

The concomitance of a migratory wave and the hospital crisis once again raises the question of the care that the French healthcare system is able to provide to migrants. On the occasion of SFFEM's 19th annual day, we present a synthesis of the research work that has been communicated at that time. Firstly, we will discuss how doctors have been able to overcome strangeness to revive the notion of hospitality according to Levinas; secondly, we will discuss how the hospital is departing from its mission of institutional hospitality because of administrative injunctions; thirdly, we will discuss how ethnomedicine gives us keys to open up to other cultural norms; fourthly, we will see the inadequacy that exists between rights of access to medical care and their effectiveness; finally, the conclusion of Xavier Emmanuelli, founder of the social ambulance service, will remind us how much the values of the French Republic call us to the notion of care and openness to otherness.

[Towards better management for sexual offenders: Presentation and conclusions of a public hearing concerning prevention, assessment, and care]. / Audition publique auteurs de violences sexuelles : prévention, évaluation, prise en charge des 14 et 15 juin 2018 : perspectives et préconisations.

In France, since the law of June 17, 1998, sexual offenders may be convicted to ambulatory mandatory care, articulated with the justice. Twenty years after the implementation of this law, while social and technological developments have redefined certain aspects of delinquency, reference documents and practice guidelines remain to be updated. This is why the professionals of the main structures and associations dealing with perpetrators of sexual violence organized a public hearing under the sponsorship of the French Federation of Resource Centers for Sexual Violence Perpetrators (FFCRIAVS) according to the methodology and with the accompaniment of the High Authority of Health. This article presents the global methodology of the public hearing "Sexual Offenders: Prevention, Evaluation and Care" which was conducted on June 14 and 15, 2018. Thirty-three experts replied to27 questions and presented their conclusions to an Audition Committee and an audience of 200 persons representative of the civil and professional society. After a public debate, the hearing committee prepared a report in which they proposed propositions in order to better care for sexual offenders.

Probing the Activity of Eukaryotic Rhomboid Proteases In Vitro.

Proteolysis within the membrane is a recent concept in biology. Rhomboid intramembrane serine proteases are conserved in evolution and serve as key switches in diverse cellular pathways ranging from signaling to protein degradation. Since deregulation of intramembrane proteolysis can lead to severe diseases including neurodegenerative disorders, dissecting their enzymatic function and specificity becomes crucial. As membrane proteins, their solubilization, and purification are technically challenging. As a start point for a comprehensive in vitro characterization of eukaryotic rhomboid proteases, we depict in this chapter a robust workflow to find the best conditions to obtain pure and active enzymes from a bacterial expression system. To monitor the integrity of their active site and visualize substrate cleavage, various established activity assays including activity-based labeling and gel-based cleavage assays are described. These methods are illustrated by use of the Escherichia coli rhomboid protease GlpG and human RHBDL2 as an example.

[Assessment of a new law for sex offenders implemented in France in 1998]. / Loi du 17 juin 1998 : bilan de l'expérience des médecins coordonnateurs de Haute Normandie.

OBJECTIVES: Most people recognize that incarceration alone will not solve sexual violence. Treating the offenders is critical in an approach to preventing sexual violence and reducing victimization. The Law of June 17, 1998, on the prevention and repression of sexual offences, as well as the protection of minors, makes a provision for the possibility of medical and psychological monitoring adapted to these particular individuals. Sex offenders may well be constrained, after their incarceration, to social and judicial follow-up, which may include coerced treatment in order to reduce the risk of recidivism. In order to control this follow-up, the legislature has created the position of medical coordinator, who acts as an interface between justice and care in conjunction with the treating physician. This study is the first attempt to evaluate the activity of physician coordinators conducted in France since the implementation in 2004 of the 1998 law on monitoring sex offenders. METHODS: An interview of all the physician coordinators in Upper Normandy was conducted. The files of all sex offenders subjected to coerced treatment were studied. RESULTS: In our sample of 100 sex offenders who were subjected to coerced treatment (any kind of treatment) (99% men, 60% of sexual assaults on minors, 14% of cases of indecent exposure), minor victims of sexual assault were: 78% females; in 90% of cases the victim was aged under 14 years (under 10 in 52% of cases), 60% of cases were intrafamilial incest; the victim was an unknown aggressor in only one case out of 60. The constraint follow-up contributed to reducing the risk of recidivism (three cases of recidivism in 100 individuals over an average duration of follow-up of five years), although it remains difficult to assess the recidivism over a duration of time as short as five years. A diagnosis of paraphilia was only applied in 19% of cases (in 10 cases pedophilia, exhibitionism in nine cases). Only six subjects were receiving antiandrogen treatment. A diagnosis based on Axis I DSM was established in 57% of cases. Personality disorders were mentioned in the medical records in 65% of cases. An antisocial personality disorder was not prominent (20%). In 56 cases, the individuals had been victims of physical, psychological or sexual abuse. Nearly half of the individuals had a past history of sexual or non sexual offences, among those, 16 subjects had previously been convicted at least three times. The seniority of the prior conviction was more than 10 years in 43% of cases. Physician coordinators interviewed were satisfied with their work and felt they had contributed to improving the care of patients who had committed sexual offences. CONCLUSION: However, this study shows the need to create a national reference centre, which could enable a multidisciplinary evaluation of difficult cases and could also boost the development of research in this area where many questions remain unanswered, particularly regarding the determinants of deviant sexual behaviour and risk factors for recidivism.

Correlación entre el Puntaje Obtenido en la Prueba "Timed up and go" y Momentos Articulares del Miembro Inferior Registrados Durante la Transferencia de Sedente a Bípedo en Adultos Mayores con Antecedentes de Caídas Frecuentes / Correlation between the Scores of "Timed up and go" Test and Registered Joint Moments of Lower Limb During the Sit-to-Stand Transfer in Elderly with Antecedents of Frequent Falls

Los cambios producidos durante el envejecimiento predisponen al adulto mayor a las caídas frecuentes, en el ambiente clínico el riesgo de caída es valorado mediante pruebas clínicas que muchas veces carecen de poder analítico, por lo cual es necesario describir cual de dichas pruebas puede tener mayor relación con parámetros biomecánicos analíticos con la finalidad de conferirle a dichas pruebas funcionales tales características. El objetivo de este trabajo fue describir la existencia de correlación entre los puntajes obtenidos en la prueba funcional "Timed up and go" (TUG) y momentos articulares del miembro inferior obtenidos durante la ejecución de la transferencia de sedente a bípedo (TSB) en sujetos adultos mayores con antecedentes de caídas frecuentes. Se obtuvo una muestra de 30 voluntarios, todos adultos mayores con antecedentes de caídas frecuentes, los que fueron evaluados con la prueba funcional de TUG. También se evaluó mediante un sistema de análisis de movimiento la TSB donde se registraron los parámetros biomecánicos necesarios para determinar los momentos articulares del miembro inferior. Existió una correlación significativa (r=-0,39; p=0,03) entre el puntaje obtenido en el TUG y el momento articular máximo de rodilla. Para la muestra evaluada, el tiempo de ejecución de la prueba "Timed up and go" fue indicador de la capacidad de generar momento articular por parte de los músculos flexo-extensores de rodilla en sujetos con antecedentes de caídas frecuentes.

The changes that take place during aging predispose the elder adult to frequent falls. In clinical practice fall risk is assessed by clinical tests that many times lack analytical power, therefore making it necessary to describe which of the clinical tests are related to the analytical biomechanical parameters in order to assign such characteristics to these functional tests. The objective of this work was to describe the existence of a correlation between the score of the functional test "Timed up and go" (TUG) and the joint moments of lower limb obtained during the execution of the sit to stand (STS) transfer in elderly subjects with a history of frequent falls. A sample of 30 volunteers was obtained; all were elders with a history of frequent falls. They were assessed with the functional test of TUG. Also assessed were the joint moments of the lower limb with motion analysis system. There is significant correlation (r=0.39; p=0.03) between the score obtained in the TUG and the maximum joint moment of the knee. For the sample assessed, the time of execution of the test "Timed up and go" was indicative of the capacity to generate a joint moment by the flexion-extensor muscles of the knee in subjects with a history of frequent falls.

[Personality tests and gender identification in male transsexuals]. / Tests de personnalité et identification sexuée chez des transsexuels masculins.

The aim of this research project was to study gender identification in male transsexuals compared to male and female controls, using the Rorschach test and the MMPI. In the international literature, many researches have shown that the nature of the human response on Rorschach card III is linked to gender identification, as is the MMPI Mf scale. Ten untreated male homosexual transsexuals and 18 treated and operated male homosexual transsexuals were compared to 10 male and 12 female controls regarding verbal IQ, human content on Rorschach card III and the MMPI Mf scale. Absence of hormonal treatment for the first group of transsexuals was checked by a blood test at the time of the psychological testing. Responses on Rorschach card III were scored according to different kinds of human contents: male (M), female (F), gender-unidentified/neutral (N), bisexual (B), feminine then masculine or the opposite (M/F), and nonhuman (NH). N, B, M/F and NH responses were rare in all Rorschach protocols. As expected, responses given by participants in the control group were significantly more consistent with their anatomical sex than with the opposite sex. Untreated transsexuals do not differ from treated and operated transsexuals on Rorschach data, and both transsexual groups give significantly more female human representations than male controls. Transsexuals' results are similar to female controls. Untreated transsexuals' mean score on the MMPI Mf scale is significantly higher than that of treated and operated transsexuals' score, in the male profile (biological sex). Both groups of transsexuals score higher on the Mf scale in the male profile than in the female profile. The mean Mf score in the male profile is significantly higher than that of male controls, whereas, in the female profile, the mean Mf score is similar to that of female controls. This study shows that for both groups of transsexuals, results are homogenous in respect of Rorschach and MMPI, showing hyper-conformism to self-perceived gender. Results in both groups are similar to results of female controls, but tend to show even more feminine gender identification. The absence of any significant difference between untreated and treated and operated transsexuals seems surprising, suggesting that the hormonal treatment has not had a major impact on gender identification processes. It would doubtless be interesting to study gender identification using even more kinds of data: all human contents in the Rorschach protocol (not just the responses given to card III), MMPI Mf scale, Draw-A-Person Test and Animal-and-Opposite Drawing Test. This would enhance result liability and could provide useful information about how gendter identification processes evolve after surgical sex reassigment.

The antecubital fasciocutaneous island flap for elbow coverage.

Soft-tissue defects in the area of the periolecranon may be a source of concern to the reconstructive surgeon who aims for durable protection with a minimum of drawbacks. Lamberty and Cormack described the antecubital fasciocutaneous flap both as a local transposition and as a free flap. The island version of this flap enables a single-stage transfer of thin, pliable, sensitive skin into the region of the periolecranon without further scarring around the defect. In general, most of the donor site can be closed primarily together with a small, full-sheet, split-thickness skin graft on the remaining skin defect on the volar surface of the distal forearm. An additional advantage of this flap is the rather straightforward dissection with minimal repercussion on the forearm contour. An anatomic overview as well as 4 patients are described to illustrate the appealing features of this fasciocutaneous flap.

[Hormone treatment of sex offenses]. / Les traitements hormonaux de la délinquance sexuelle.

In humans, roles for androgens have been described in the regulation of sexuality, aggression, cognition, emotion and personality. Recent advance in the understanding of factors that are associated with sexual aggression have led to improved methods of treatment. A number of organic treatments which reduce the plasma testosterone levels or decrease androgen effects on target cells are available. These treatments may reduce the chance of reoffending of sexually aggressive men. The authors will review the literature on orchidectomy, oestrogens or progestogens such as medroxyprogesterone acetate (MPA) or cyproterone acetate (CPA) which are currently used in the treatment of deviant sexuality. From now, orchidectomy and treatment with either estrogens or MPA are withdrawn. The authors will also report the good clinical efficacy of a GnRH analogue (triptoreline) in eleven sex offenders. When used in conjunction with psychotherapy, they may benefit sex offenders especially in those who are motivated for treatment.

[Mass screening programs for breast cancer in France. Comparative evaluation]. / Les programmes de dépistage de masse du cancer du sein en France. Evaluation comparative.

OBJECTIVE: The purpose of this work was to comparatively assess the results of mass screening programs for breast cancer implemented in six French departments in 1986, within the scope of the National Fund for Health Prevention, Education and Information of the National Health Insurance Office of Salaried Workers. MATERIAL AND METHODS: The data collected by the screening centres were analyzed by ten assessment teams that were independent from the program promotion staff, all using the same evaluation form. A complementary population study performed in eight French districts then, allowed assessing the frequency of self-referred screening (mammography performed out of program). RESULTS: The rate of participation in screening programs, in relation to the invited population, ranged from 21 to 48%, according to the district (36% in average). This low participation was probably related to the extent of self-referred screening. In fact, 19 to 40% of women, according to the district, had previously had a screening mammographic coverage: rate was around 68% in women aged 50 to 69 years. Positive findings with mammography ranged from 4.5 to 15.8% (10.1% in average), while intervention rates ranged from 0.7 to 1.6% and detection rates from 3.8 to 6.2%. The ratio between benign tumors and cancers ranged from 0.7 to 2.1 according to the district. In order to enlighten the judgement on French results, we propose a comparison with the international standards in force. CONCLUSION: The various experiences with breast cancer screening in France show that this screening is technically feasible on the basis of existing medical structures. However, some criteria are still below the expected values, especially if compared with international standards. This result is probably accounted for by the high rate self-referred screening before age 40 in France. In these conditions, the question is whether extending breast cancer screening programs in France is an appropriate course of action.

[The transsexualism syndrome: clinical aspects and therapeutic prospects]. / Le syndrome de transsexualisme: aspects cliniques et perspectives thérapeutiques.

The prevalence rate of transsexualism varies from 1 to 50,000, to 1 to 100,000. Although it remains an infrequent affliction, transsexualism generates usually major suffering and may be responsible of many complications like suicide, self-mutilations, affective disorders and social disabilities. Since the first descriptions of Esquirol in the nineteenth, the medical community has always been questioned on medical, legal, social or ethical aspects of transsexualism. The aetiology of the trouble is still unknown. In the absence of biological marker, the syndrome of transsexualism can be defined only with clinical criteria. The main differential diagnosis are sexual ambiguities and psychotic disorders. For the specialists, satisfying the patients demand of a surgical and social reassignment still remains the only way to improve their clinical condition and avoid the onset of many dramatic complications. Without any treatment, the evolution of the trouble is chronic, without remission. Longitudinal studies of transsexual patients with a five year follow-up demonstrated subjective improvement in two thirds of the patients and don't find either higher rates of suicides nor psychotic decompensations after surgery and hormonotherapy. Clinical and neuropsychological studies of sexually differentiated cognitive abilities of transsexual patients, before and after hormonotherapy, could allow us in improving the understanding of sexual differences of the brain.

The effect of fluoxetine on anxiety and depression symptoms in cancer patients.

Little has been done to study the effectiveness of antidepressants in controlling anxiety/depression in a population of cancer patients. A double-blind placebo-controlled study was therefore designed to assess the effectiveness of 20 mg fluoxetine. Of 115 cancer patients who fulfilled entry criteria for levels of distress, 45 patients were randomized to a fluoxetine treatment group (FA) and 46 patients to a placebo group (PA) after a 1-week placebo period designed to exclude placebo responders. The Montgomery and Asberg Depression Scale (MADRS), the Hamilton Anxiety Scale (HAS), the Hospital Anxiety and Depression Scale (HADS), the Revised Symptom Checklist (SCL90-R) and the Spitzer Quality of Life Index (SQOLI) were used to assess the efficacy of fluoxetine. The response rate, defined by a HADS score lower than 8 after 5 weeks of treatment, was not significantly higher in the FA group (11%) compared to the PA group (7%). Compared to the PA group, patients in the FA group showed a significantly greater decrease in SCL90-R mean total score after 5 weeks, but not a greater decrease in HADS mean score. No difference between the two groups was found in observer-reported assessments (MADRS, HAS and SQOLI). Significantly more drop-outs were observed in the FA group (n = 15) than in the PA group (n = 7), although the frequencies of side-effects were not significantly different.

[Psychiatric aspects of transsexualism]. / Aspects psychiatriques du transsexualisme.

Transsexualism is a mental disease in which gender identity goes contrary to corporal reality. Diagnostic is purely clinical and needs a prolonged observation. The actual experience concerning about 700 cases allow us to consider that one quarter of patients should get sexual conversion.

Gonadotrophin hormone releasing hormone agonist in cases of severe paraphilia: a lifetime treatment?

Six patients with severe paraphilia were treated with a long-acting gonadotrophin hormone releasing hormone analogue (GnRH-a). In five cases, the antiandrogen treatment ended their deviant sexual behaviour and markedly decreased their sexual fantasies and activities without significant side-effects. The beneficial effects of this treatment were maintained for 7 years in the patient where there was the longest follow-up. Two patients abruptly withdrew front their antiandrogen treatment at the end of the first and third year, respectively. Both relapsed within 8-10 weeks. One of them asked for resumption of antiandrogen treatment. In another case, in order to phase out antiandrogen treatment, testosterone (T) was added to the GnRH-a. In spite of normal T levels, and of resumption of normal sexual activities and deviant fantasies, deviant sexual behaviour did not return. A smoother phasing out of GnRH-a treatment is thought to be better than an abrupt withdrawal. However, the duration of antiandrogen treatment necessary to ensure a complete disappearance of deviant sexual behaviour remains uncertain, but is at least 4 years.

[Hormonal treatments for disorders of sexual conduct]. / Traitements hormonaux des troubles des conduites sexuelles.

Because of the limits of justice, our society turns itself towards the medical need and demands efficient treatments. Mutilating neuro-surgery and treatment with estrogens have been used and then stopped. Medroxyprogesterone (MPA) and Cyproterone (CPA) acetate have been proved to be efficient in 80% of cases studied and published. However the therapeutic use of CPA is limited in France by three drawbacks: exclusive oral route of administration, lack of available biological criteria as a control of good observance and lack of official indication. Therefore the authors studied a GnRH analogue (triptorelin) which induces a reversible hormonal castration and which is administered by I.M. route monthly. It was efficient in five out of six aggressive hypersexual patients. An ethical study is proposed after which the authors call for an evolution of the mentalities about this question.

[Ethnic conflicts and environmental degradation in Central Asia. The Ferghana valley and northern Kazakhstan]. / Conflits ethniques et degradation ecologique en Asie centrale. La vallee de Ferghana et le nord du Kazakhstan.

PIP: This work seeks to demonstrate that the combination of ecological degradation, demographic pressure, and ethnic heterogeneity in Central Asia constitute a serious threat to the future stability of the region. The predominantly rural Ferghana Valley and Northern Kazakhstan suffer from shortages of water and land and from unemployment that leads to extensive out-migration to cities suffering from decline in their Soviet-era industries. The problem in the Ferghana Valley began with Tsarist conquest of the valley in 1876 and the subsequent imposition of cotton cultivation, which was greatly expanded by the Soviet Union. The Ferghana Valley, despite being a natural unit, was divided between Uzbekistan, Tajikistan, and Kyrgyzstan in the 1920s and 1930s, and remains divided between the independent states. The current population of 11 million is ethnically diverse, with Uzbeks in the majority and increasing most rapidly. Immigration from the Caucasus since 1950 added to the tension. Future peace will depend on such factors as whether the neo-Communist political regime chooses to incite ethnic hostilities, the manner in which land is redistributed, and the outcome of struggles for control of the flourishing narcotics trade. The northern Kazakhstan region was designated a pioneer wheat-growing region by Soviet planners in 1954. Russian and Ukrainian migrants established between 1954 and 1956 are today the predominant population sector, but feel their privileged position threatened by nationalist policies making Kazakh the official language and giving preference in employment to Kazakhs. Resettlement of Kazakhs from Mongolia, China, and Afghanistan in the region and the high Kazakh birth rate increase tensions. Grain production initially grew rapidly, but the mediocre soil and erosion-inducing constant dry winds have caused production to stagnate or decline. Regional disputes within Kazakhstan complicate the situation. Northern Kazakhstan, with its industrial development, is integrated more with the Urals and Western Siberia than with the rest of Kazakhstan. Serious ethnic conflicts in either Kazakhstan or the Ferghana Valley are likely to spill far beyond their local boundaries, embroiling much of the area in hostilities.^ieng

[Drug modulation of libido and sexual activity. Behavior effect of GnRH analog in man]. / Modulation médicamenteuse de la libido et de l'activité sexuelle. Effet comportemental d'un analogue de la GnRH chez l'homme.

Libido and male sexual behaviour are under the control of complex testosterone-dependent neuro-endocrine mechanisms. Better knowledge of these mechanisms has allowed to modulate sexual behaviour using drugs. Indeed, it is possible to block spontaneously uncontrollable sexual pulsions of aggressive hypersexual men by dropping testosterone secretion and consecutively decreasing androgen effects on target cells. From now, mutilating neurosurgery and treatment with either estrogens or antigonadotrophic progestagens are withdrawn. Cyproterone acetate, acting as a competitive inhibitor of testosterone action through its binding to androgen receptors, has been used with efficacy in 80% of cases studied. However, the therapeutic use of cyproterone acetate is limited by three drawbacks: i/potential side effects, ii/exclusive oral route of administration and iii/lack of available biological criteria as a control of the good observance of the treatment. We studied the efficacy of a GnRH analogue (Triptoreline), which induces a reversible hormonal castration and of which both the formulation and the route of administration avoid the inconveniences linked to a treatment with cyproterone acetate. 3.75 mg triptoreline injected intramuscularly once a month had been very effective on clinical and biological parameters in 5/6 aggressive hypersexual patients. In 3 of them a previous treatment with cyproterone acetate had been uneffective. Such a reversible hormonal castration suppressing sexual addiction, would lead to favourable conditions for psychotherapy.

Effect of a long-lasting gonadotrophin hormone-releasing hormone agonist in six cases of severe male paraphilia.

Six men with severe paraphilia had been treated with depot gonadotrophin luteinizing releasing hormone analogue (GnRHa) (triptorelin 3.75 mg per month intramuscularly). In 5 cases, the treatment ended their deviant sexual behavior and markedly decreased their sexual fantasies and activities without further significant side effects than those related to hypoandrogenism. This clinical improvement was parallel to the gradual decrease of plasma testosterone level to castration values within the first month. The beneficial effect of this treatment had been maintained at follow-up varying from 7 months to 3 years. One patient interrupted the treatment at the end of the first year and relapsed within 10 weeks. GnRHa treatment, which leads to reversible castration, may constitute a promising treatment of paraphilic behavior and may favor the possibility of concurrent psychotherapy.