[Revive the life pulsion: the geriatric psychiatry day care hospital]. / Relancer la pulsion de vie: l'hôpital de jour de psychiatrie gériatrique.

Old age with its succession of losses is a vulnerable phase in life for developing or exacerbating mental illnesses. Pragmatically, we can identify three types of senior patients: patients presenting behavioral and psychological symptoms of dementia, patients affected by a chronic mental illness, patients experiencing a first major psychiatric syndrome in later life. The purpose of this article is to describe the specific programs developed by the day care hospital of the Geriatric Psychiatry Service, Geneva University Hospitals, to respond to the need of these groups of patients as well as their relatives. This community psychiatric care intends to provide a better psychological adaption in order to support functional and social recovery.

L'âge avancé, avec son lot de pertes potentielles, favorise l'apparition ou l'exacerbation de troubles psychiatriques. On peut identifier trois types de patients âgés avec troubles psychiatriques: ceux présentant des symptômes psycho-comportementaux qui apparaissent en lien avec l'évolution d'un trouble neurocognitif, ceux avec une maladie psychique chronique et ceux vivant une première manifestation d'un syndrome psychiatrique à l'âge avancé. Cet article vise à décrire les programmes spécifiques que l'hôpital de jour du Service de psychiatrie gériatrique, HUG, a développés pour répondre aux besoins de ces trois types de patients ainsi qu'à ceux de leurs proches. Ces soins de psychiatrie communautaire visent à apporter aux patients un meilleur équilibre psychologique en vue de leur rétablissement fonctionnel et social.

Autoimmunity Against the Heart and Cardiac Myosin in Children With Myocarditis.

BACKGROUND: Host autoimmune activity in myocarditis has been proposed to play a role in development of cardiac disease, but evidence of autoimmunity and relationship to outcomes have not been evaluated in pediatric myocarditis. METHODS: We performed a multi-institutional study of children with clinical myocarditis. Newly diagnosed patients were followed for up to 12 months and previously diagnosed patients at a single follow-up for serum levels of autoantibodies to human cardiac myosin, beta-adrenergic receptors 1 and 2, muscarinic-2 receptors, and antibody-mediated protein kinase A (PKA) activation in heart cells in culture. Results were compared with those of healthy control children. RESULTS: Both previously diagnosed patient at follow-up (P = .0061) and newly diagnosed patients at presentation (P = .0127) had elevated cardiac myosin antibodies compared with control subjects. Antibody levels were not associated with recovery status at follow-up in either group. PKA activation was higher at presentation in the newly diagnosed patients who did not recovery normal function (P = .042). CONCLUSIONS: Children with myocarditis have evidence of autoantibodies against human cardiac myosin at diagnosis and follow-up compared with control subjects. Differences in antibody-mediated cell signaling may contribute to differences in patient outcomes, as suggested by elevated antibody-mediated PKA activation in heart cells by the serum from nonrecovered patients.

High Frequency of Detection by PCR of Viral Nucleic Acid in The Blood of Infants Presenting with Clinical Myocarditis.

Specific viruses are associated with pediatric myocarditis, but the prevalence of viral DNAemia detected by blood polymerase chain reaction (PCR) is unknown. We evaluated the prevalence of known cardiotropic viruses (enterovirus, adenovirus, human herpesvirus 6, and parvovirus B19) in children with clinical myocarditis (n = 21). Results were compared to pediatric controls with similar viral PCR testing. The majority of positive PCR (89 %) was noted in children ≤12 months of age at diagnosis compared to older children. Infant myocarditis patients (8/10) had increased the prevalence of PCR positivity compared to infant pediatric controls (4/114) (p < 0.0001). Other than age, patient characteristics at diagnosis were similar between PCR-positive and PCR-negative patients. Both PCR-negative myocarditis infants had clinical recovery at follow-up. Of the PCR-positive myocarditis infants, 4 had clinical recovery, 2 developed chronic cardiomyopathy, 1 underwent heart transplant, and 1 died. Infants with clinical myocarditis have a high rate of blood viral positivity, which is higher compared to older children with myocarditis and healthy infant controls. Age-related differences in PCR positivity may be due to differences in host and/or virus characteristics. Our findings suggest that viral blood PCR may be a useful diagnostic tool and identify patients who would potentially benefit from virus-specific therapy.

A One-Health Approach to Investigating an Outbreak of Alimentary Tick-Borne Encephalitis in a Non-endemic Area in France (Ain, Eastern France): A Longitudinal Serological Study in Livestock, Detection in Ticks, and the First Tick-Borne Encephalitis Virus Isolation and Molecular Characterisation.

Tick-borne encephalitis virus' (TBEV) geographic range and the human incidence are increasing throughout Europe, putting a number of non-endemic regions and countries at risk of outbreaks. In spring 2020, there was an outbreak of tick-born encephalitis (TBE) in Ain, Eastern France, where the virus had never been detected before. All patients but one had consumed traditional unpasteurised raw goat cheese from a local producer. We conducted an investigation in the suspected farm using an integrative One Health approach. Our methodology included (i) the detection of virus in cheese and milk products, (ii) serological testing of all animals in the suspected farm and surrounding farms, (iii) an analysis of the landscape and localisation of wooded area, (iv) the capture of questing ticks and small mammals for virus detection and estimating enzootic hazard, and (v) virus isolation and genome sequencing. This approach allowed us to confirm the alimentary origin of the TBE outbreak and witness in real-time the seroconversion of recently exposed individuals and excretion of virus in goat milk. In addition, we identified a wooded focus area where and around which there is a risk of TBEV exposure. We provide the first TBEV isolate responsible for the first alimentary-transmitted TBE in France, obtained its full-length genome sequence, and found that it belongs to the European subtype of TBEV. TBEV is now a notifiable human disease in France, which should facilitate surveillance of its incidence and distribution throughout France.

Reasons for ineffective contraceptive use antedating adolescent pregnancies part 1: an indicator of gaps in family planning services.

PURPOSE: Identify new ways to increase the impact of pregnancy prevention interventions on the number of children born to adolescents. METHODS: The study participants, a racially/ethnically diverse group of 1,568, pregnant 13-18 year olds, reported why they had not used contraception at the time of conception. Their explanations were sorted into categories. The frequency with which each category was endorsed, the stability of these endorsements (Kappa statistic), and differences between adolescents who endorsed each category (stepwise logistic regression) were examined at two points in gestation. RESULTS: "Not ready to prevent pregnancy" was the most frequently endorsed category; it was often the only category endorsed. Logistical barriers and misperceptions about the need for contraception were the least frequently endorsed categories. The reasons individual patients gave for not using contraception changed (K < or = 0.4) during gestation. Yet, adolescents who were not ready to prevent conception consistently differed from those who were; they were more apt to be Hispanic, to live in non-chaotic environments with an adult father of the child rather than their parents, and to have goals compatible with adolescent childbearing. CONCLUSIONS: The most expedient way to strengthen the impact of pregnancy prevention programs on adolescent childbearing is to shift the focus of intervention from overcoming logistical barriers and misperceptions about the need for contraception, to helping young women develop goals that make adolescent childbearing a threat to what they want in life. This means intervening actively enough to ensure that goal setting translates into an internal desire to postpone childbearing beyond adolescence.

Reasons for ineffective contraceptive use antedating adolescent pregnancies: part 2: a proxy for childbearing intentions.

PURPOSE: Compare the relationship between childbearing intentions, maternal behaviors, and pregnancy outcomes in a group of early/middle adolescents versus a group of late adolescents (specifically high school seniors, high school graduates, and GED certificate recipients). METHODS: The reasons given by a racially/ethnically diverse group of 1,568 pregnant 13-18 year olds for not using contraception were used to classify their pregnancies as intended or unintended. Proportion comparison tests and stepwise logistic regression analyses were used to study the relationship between childbearing intentions, maternal behaviors, and pregnancy outcomes. RESULTS: Regardless of age, adolescents who intended to become pregnant conceived in an objectively more hospitable and supportive childbearing milieu than those who conceived unintentionally. This is evidenced by their greater likelihood of having goals compatible with adolescent childbearing, cohabitation with the father of the child, and living in a non-chaotic environment. However, pregnancy planning was not associated with improved compliance with preventive health care recommendations during gestation nor with infant outcomes. As such, the consequences among adolescents with intended pregnancies were negative, as evidenced by a higher rate of smoking, STDs late in gestation, school dropout, and repeat conception. CONCLUSIONS: Like adults, adolescents with intended pregnancies conceived in an objectively more supportive environment than their counterparts with unintended pregnancies. However, this advantage did not translate into better support, healthier maternal behavior during gestation, or improved pregnancy outcomes.

Age at menarche and first pregnancy among psychosocially at-risk adolescents.

We sought to determine which factors influence the association between menarche and conception among adolescent study participants (n = 1030), who demonstrated an earlier age of menarche than did national samples. Age at first sexual intercourse (coitarche) mediated the relationship between age at menarche and first pregnancy among White girls, whereas gynecologic age at coitarche (age at coitarche minus age at menarche) and age at menarche explained the timing of the first pregnancy among Black and Hispanic girls. Pregnancy prevention interventions to delay coitarche should also include reproductive education and contraception.

Association of conventional goals and perceptions of pregnancy with female teenagers' pregnancy avoidance behavior and attitudes.

CONTEXT: Fostering conventional goals is a key component of pregnancy prevention interventions for teenagers. However, research has not shown whether having goals independently influences sexual behavior, or whether the perception that pregnancy represents an impediment to achieving goals mediates any association. METHODS: In 1999-2001, a racially mixed group of 351 sexually experienced female teenagers who were inadequate contraceptive users completed surveys about goals, the anticipated impact of childbearing on these goals, and protective behaviors and attitudes. Chi-square, regression and two-by-two table analyses assessed associations between goals and perceptions of early childbearing and pregnancy avoidance measures. RESULTS: Three-fourths of respondents had educational or vocational goals. Eight in 10 of these teenagers perceived their goals to be achievable, but fewer than half thought pregnancy would be an impediment to achieving these goals. Teenagers who had goals were more likely than others to have used a contraceptive at last intercourse (odds ratio, 1.9), but controlling for the perception of pregnancy as an impediment eliminated this association. In contrast, considering pregnancy an impediment was associated with an increased likelihood of supporting each pregnancy avoidance measure (2.1-9.6), and of intending to avoid pregnancy and to have an abortion if pregnant, regardless of whether teenagers had goals (8.3-13.8). CONCLUSIONS: Conventional goals appear to motivate teenagers to avoid getting pregnant only if they believe pregnancy will be an impediment. Thus, it may be less important to encourage young women to formulate goals than to ensure that they consider adolescent childbearing a threat to their plans.

Characteristics of adolescent women who stop using contraception after use at first sexual intercourse.

STUDY OBJECTIVE: Identify correlates of contraceptive discontinuation, which if modified, might make teenagers more, not less, effective contraceptors as they age. SETTING: Teen clinic. PARTICIPANTS: Teenagers who used contraception at first intercourse (N = 120). Some "never" used contraception during the 4 months immediately prior to the survey ("contraceptive stoppers"; n = 38). The others (n = 82) did so "always" or "most of the time" ("consistent contraceptive users"). INTERVENTIONS: Questionnaire responses were used to determine univariate and multivariate associations between contraceptive use group and five categories of factors: inability to plan for sex, belief that pregnancy is unlikely to occur, belief that contraceptives are unsafe, inability to negotiate contraceptive use, and lack of desire to remain non-pregnant. MAIN OUTCOME MEASURE: Odds of being a contraceptive stopper. RESULTS: In univariate analyses contraceptive stoppers scored significantly higher on scales that assessed inability to plan for sex, belief that pregnancy is unlikely, and lack of desire to remain non-pregnant. Contraceptive stoppers were also older and more likely to have been sexually active for at least 6 months. In multivariate analyses, those who were sexually active for at least 6 months (odds ratio [OR]: 2.9, confidence interval [95%CI]: 1.1-7.1), those who believed that pregnancy was unlikely (OR: 3.8; 95% CI: 1.7-8.6), and those who lacked the desire to remain non-pregnant (OR: 2.7; 95% CI: 1.4-5.1) were more likely to stop using contraception. CONCLUSIONS: Our findings suggest that teens who use contraception at coitarche stop doing so as they mature sexually because they begin to doubt the necessity and desirability of using contraceptives. Longitudinal studies are needed to determine if such doubts are preventable and if doing so encourages teens to continue to use contraception.

Maternal age and the size of White, Black, Hispanic, and mixed infants.

OBJECTIVE: To clarify the interaction between maternal age and race in the prediction of infant size at birth. METHODS: Birth certificate data was used to study the relationship between maternal age, race/ethnicity, and the size of term, singleton infants born to 91,061 healthy, non-smoking, non-substance using, primigravidas. RESULTS: Maternal race/ethnicity (Black race: OR: 1.95, 95% CI: 1.49-2.56; Hispanic ethnicity: OR: 1.38, 95% CI: 1.19-1.61) and the interaction term, maternal age x race/ethnicity (OR: 1.06, 95% CI: 1.01-1.11) predicted small-for-gestational age (SGA) birth. The strength of the association between Black race and SGA delivery increased and the strength of the association between Hispanic ethnicity and SGA delivery decreased with age (P < 0.001 for trend). Thus, Black and Hispanic teenagers were more likely to have SGA babies than White teenagers (1.7% and 1.6%, respectively compared to 1.2%; P = 0.003). However, Black women who postponed childbearing until their mid-twenties were more likely to have SGA babies than their Hispanic and White counterparts (2.6% compared to 1.2%, and 1.0%, respectively; P < 0.0001). CONCLUSION: The findings suggest that acquired maternal characteristic(s) cause the reproductive health of Black primigravidas to deteriorate and Hispanic primigravidas to improve with age.

Why lightning strikes twice: postpartum resumption of sexual activity during adolescence.

PURPOSE: To describe the circumstances surrounding the postpartum resumption of sexual activity in a cohort of teenage mothers. The goal was to shed new light on the reasons why teenagers who have just given birth put themselves at risk for conception. METHODS: A racially and ethnically diverse group of 267 poor, predominantly unmarried, primiparous, 13-21 year olds was enrolled consecutively at delivery and followed through the third postpartum month. The primary outcome measure was weeks postpartum at resumption of sexual activity, further categorized as protected or unprotected. The analysis controlled for factors thought to influence the postpartum resumption of sexual activity among adult couples and the use of contraception during adolescence. The Kaplan-Meier method was used to estimate the time to end point and Cox proportional-hazards regression analysis to compute relevant relative risks (RR). RESULTS: By the end of the third postpartum month, 58% of the teenagers had had sexual intercourse and the majority (80%) used contraception when they did so. The median time to first coitus, 10.7 weeks, was unrelated to contraceptive use but was significantly shorter among teenagers who lived with their boyfriends (RR: 2.4; 95%CI: 1.7-3.4) and those who delivered prior to term (RR: 2.1; 95%CI: 1.3-3.6). The analysis revealed that the teenagers who did not use contraception at first postpartum sexual intercourse exhibited more theorized risk factors for conception than those who did and those who remained sexually abstinent. CONCLUSIONS: This new empirical evidence that coital activity resumes soon after delivery should dispel the normative belief that contraception is unnecessary during the puerperium. Early contraceptive vigilence may also decrease the frequency and rapidity with which teen mothers conceive, as the differences in the prevalence of teen pregnancy risk factors we uncovered suggest that decisions about using contraception (not sexual intercourse) determine the risk of rapid repeat conception. Teens with live-in boyfriends and premature babies are especially apt to benefit from the new information in this report as they resume sexual activity sooner than their peers and are less apt to use contraception when they do so.

Non-ischemic left ventricular dysfunction after pediatric cardiac transplantation: treatment with plasmapheresis and OKT3.

BACKGROUND: Acquired left ventricular dysfunction after pediatric cardiac transplantation is associated with a high mortality rate. It often occurs without biopsy evidence of cellular rejection or severe transplant coronary arteriopathy. METHODS: We employed a protocol for treatment of acquired, non-ischemic left ventricular dysfunction utilizing plasmapheresis, monoclonal anti-T-cell antibody (OKT3), cyclophosphamide and steroids, regardless of the results of endomyocardial biopsy. Left ventricular dysfunction was defined as an echocardiographic shortening fraction of <29% and/or symptoms of congestive heart failure requiring inotropic support. Transplant coronary arteriopathy was excluded by coronary angiography in all cases. RESULTS: Ten pediatric heart transplant recipients were treated for 13 episodes of non-ischemic left ventricular dysfunction. Biopsy scores were low grade (ISHLT Grade 1A or 1B) in 8 episodes. Eight of 10 patients had a history of non-compliance in regularly taking immunosuppressant medications. Inotropic support was required in 9 of 13 cases, with a median duration of 5 days. Median left ventricular shortening fraction was 17% at time of presentation. Normalization of shortening fraction occurred a median of 40 days from the start of treatment. Survival to hospital discharge occurred in 11 of 13 (85%) patients. Long-term patient survival, however, was only 50% at 24 months after presentation with a first episode of acquired left ventricular dysfunction. CONCLUSIONS: Use of plasmapheresis, OKT3, cyclophosphamide and steroids resulted in successful short-term reversal of non-ischemic left ventricular dysfunction in pediatric heart transplant patients, but long-term survival remained poor.

Does incomplete growth and development predispose teenagers to preterm delivery? A template for research.

Pregnant teenagers are in better physical condition, suffer from fewer chronic diseases, and engage in fewer health-risky behaviors than socioeconomically similar pregnant adults, but give birth to a disproportionately large number of preterm infants. This systematic review of the adolescent pregnancy literature defines the unique risks associated with being young and pregnant by examining how the physical and psychosocial changes that are characteristic of puberty and adolescence interact with traditional risk factors for preterm delivery. The need for age-specific interventions is discussed and recommendations for future research are made.

Limb pain associated with an undiagnosed hemoglobinopathy and pseudononcyesis.

Over a 2-month period, a 16-yr-old African-American female presented with recurrent episodes of severe, migratory limb pain. Sickle cell C disease was ultimately diagnosed. She adamantly denied sexual activity but was found to be 28 weeks pregnant. Her limb pain was probably triggered by the metabolic and hemodynamic demands of pregnancy. The case illustrates the importance of thoroughly examining patients with recurrent, unexplained physical complaints.

Paradoxical adolescent reproductive decisions.

OBJECTIVE: To determine why teenagers who say they do not plan to parent if they become pregnant fail to use contraceptives consistently enough to avoid conceiving by default. METHODS: A racially diverse group of 333 inadequately contracepting, nulligravida teens, 45 (13.5%) of whom did not plan to parent if they became pregnant was studied. Participants completed scales assessing traditional teen pregnancy risk factors, deterrents to contraceptive use, expectations about the effect of pregnancy, the desire to remain non-pregnant, and sexual behavior. RESULTS: Teens who said they would not parent if pregnant were less apt to report boyfriends who wanted them to conceive (RR=0.7; 95% CI=0.5-0.9) and deterrents to contraceptive use (RRs around: 0.6; 95% CI: 0.3-0.9) and more apt to anticipate that childbearing would negatively impact their lives (RR: 1.9; 95% CI: 1.6-2.2), to want to remain non-pregnant (RR: 2.2; 95% CI: 1.8-2.4), and to have used contraception at last sexual intercourse (RR: 1.8; 95% CI: 1.3-2.4). In the group that did not intend to parent the only difference between those who had and had not used contraception at last intercourse was their willingness to plan for sexual activity (OR: 4.6; 95% CI: 1.3-16.7). CONCLUSION: This study suggests that further progress toward preventing unwanted teen pregnancies might be made by dispelling the notion that for young, unmarried women, unplanned sexual intercourse is preferable to planned sexual intercourse.

The Electronic Report on Adolescent Pregnancy (ERAP).

PURPOSE: To create a data management system that: (1) standardizes antecedent, program, and outcome variables relevant to the shared goals of adolescent-oriented maternity programs while allowing users to add variables pertaining to unique aspects of their work; (2) cues providers to physiologic and psychosocial characteristics that predispose teenagers to adverse pregnancy and parenting outcomes, (3) standardizes patient care by guiding providers through adolescent-oriented prenatal, postpartum, and well baby visits, and (4) establishes the infrastructure to collect data from a nationally representative sample of pregnant and parenting teens. METHOD: We adapted a powerful, state-of-the-art relational database framework (Microsoft Access 2000) to create an easy-to-use data management system-The Electronic Report on Adolescent Pregnancy (ERAP)-that requires minimal training to use on a personal computer. RESULTS: ERAP is designed to meet the administrative and analytic needs of adolescent-oriented maternity programs. It consists of six linked core data tables (teen, pregnancy, prenatal visits, child, interconception interval, and interconception interval visits), that allow users to analyze data from these multiple views while preserving the family structure. In addition, the database standardizes methods for collecting and storing the information and automatically computing the variables needed to monitor and evaluate an adolescent-oriented maternity program. Since by adding variables and appending supplementary tables, users can modify the core database to accommodate unique aspects of their programs and/or research, ERAP is also an ideal conduit for translating research findings into clinical practice. Similarly, because ERAP actually structures the care patients receive, the database provides the infrastructure needed to develop and implement best practice guidelines for treating teen-headed families. Finally, the confidentiality of all subject data is assured because ERAP is password-protected and automatically prepares files for batched external analyses by removing personal identifiers. CONCLUSIONS: ERAP provides the infrastructure needed to create a teen-pregnancy databank at the national level and an efficient patient monitoring system at the program level. By standardizing variable definitions and data collection techniques, serving as a repository for data collected at multiple sites, and tracking the multidisciplinary aspects of the care patients receive, ERAP has the potential to facilitate collaboration between adolescent-oriented maternity programs, increase the scientific rigor of teen pregnancy research, and improve the quality of care individual teen-headed families receive by prompting compliance with best practice guidelines.

Is this patient insulin resistant? How much does it matter?

Alex was an obese 10-year-old girl with a family history of type 2 diabetes, hypertension, and perhaps polycystic ovarian syndrome. Her physical examination was significant for a central accumulation of body fat and acanthosis nigricans. Although the laboratory studies indicated that Alex was not diabetic and probably not glucose intolerant, she could be insulin resistant (IR). Should any further evaluation be done? If Alex is IR, what kind of treatment should be offered? The following discussion addresses these questions by reviewing the pathophysiology, diagnosis, and consequences of isolated IR.

Assessment of the oral health status of school children in Addis Ababa.

Oral disease is a major health problem worldwide, and in Ethiopia there is very little epidemiological research done in this field in recent times. This study was carried out to provide baseline information on the major oral health problems (dental caries, periodontal disease, malocclusion, and dental fluorosis) among school children in Addis Ababa. The study was school-based cross-sectional by design. It was conducted in April 2000 with the objective to determine the oral health status of school children who are 12 years and above. A total of 1736 study subjects were selected through a multi-stage sampling procedure from three different categories of schools (private, public and government), proportionate to their respective size of student population. The prevalence of dental caries was determined to be 21.1% and it was found to increase significantly with increasing age, high consumption of sweets, and in those who do not clean their teeth regularly. Periodontal disease affected more than half (53.4%) of the study subjects and was significantly higher in males, those with high consumption of sweets, and those having 'Injera' as staple diet, and those with poor oral hygiene. The prevalence of malocclusion was 23.7%, while crowding and spacing of teeth were found in 23.8% and 18.3% of the subjects, respectively. The prevalence of dental fluorosis was low (1.6%). Health education programs, about healthy diet and practices of adequate oral hygiene, should be promoted in schools through integration into the school curriculum and services.