[Work satisfaction and exhaustion among psychiatrists in psychiatric emergency services]. / Facteurs de satisfaction et d'épuisement des psychiatres aux urgences.

BACKGROUND AND AIM: Psychiatric emergency services (PES) have recently occupied a new and growing place in the landscape of mental health services. However, few data are available on the way psychiatrists practice in the PES. Our aim was to survey psychiatrists working in PES, focusing on their job satisfaction and the theoretical models they use in their everyday practice. METHOD: We sent a survey to a sample of 508 psychiatrists working in PES in France. RESULTS: Two hundred and thirty-seven psychiatrists returned the survey, yielding a response rate of 47%. On a 0 to 10 scale, the mean level of job satisfaction was 6.7 (SD: 1.92). Participants reported that facing a variety of clinical situations and playing a key-coordinating role in the mental health system were the two most specific features of emergency psychiatry. The main sources of dissatisfaction were organizational issues and stressful clinical experiences, including violence or hostility. Sixty-three percent (n=150) of participants reported using more than two theoretical models in their practice, while the use of crisis models was reported by almost 40% of them. When assessed for suggestions to improve the PES, the majority of participants indicated that efforts should be focused on organizational factors. CONCLUSION: While emergency psychiatry could appear as an ungrateful practice, the majority of psychiatrists who responded to our survey reported satisfaction with their work and highlighted its unique particularities. Future research and collaborations are needed to identify organizational models of PES and their better integration in mental health networks.

Necrotic adenoids in post-transplant lymphoproliferative disorders.

PROBLEM: Post-transplant lymphoproliferative disorders (PTLD) are a potentially fatal complication after solid organ transplantation. The majority of cases are associated with Epstein Barr virus infection (EBV). The first manifestations of PTLD are frequently observed in the ENT area with adenoidal and/or tonsillar enlargement. METHODOLOGY: We present the case of a 12-year old girl with a total nasal obstruction and tonsillitis five months after a kidney transplantation for bilateral congenital kidney hypoplasia. RESULTS: The EBV genome was detected by polymerase reaction three months after surgery. Fiberoptic examination revealed an obstructive necrotic mass in the naso-pharynx. The anatomic-pathologic analysis revealed necrotic adenoids. CONCLUSIONS: Necrotic tonsillitis is common. Necrosis of the adenoids, although rarer, can also occur and explains the important respiratory distress. Since two thirds of PTLD patients present with clinical symptoms in the ENT area, the otorhinolaryngologist should be aware of this complication.

Variability of blood pressure response to orthostatism and reproducibility of the diagnosis of orthostatic hypotension in elderly subjects.

BACKGROUND: Orthostatic hypotension (OH) is a major problem in the elderly population. Its diagnosis is based on measurement of the blood pressure (BP) response to orthostatism (BPRO). This study investigates the within-day and day-to-day variability of the BPRO and the reproducibility of the diagnosis of OH in this population. METHODS: BP was measured in the supine position and after 1 and 2 minutes of orthostatism in 53 consecutive elderly patients (43 women and 10 men aged 83.7 +/- 9.5 years) of an intermediate care geriatric ward. BPRO was assessed 4 times on the same day (8-9 AM, 10-11 AM, 1-2 PM, and 5-6 PM) and twice more on another day of the same week (8-9 AM and 1-2 PM). RESULTS: There were significant within-day differences between the four orthostatic changes in systolic BP (OCs, supine minus standing systolic BP) after 1 minute or 2 minutes (p < .05). Day-to-day differences between the OCs measured at the same times were not significant. OH defined as an OCs of 20 mm Hg or more at 1 or 2 minutes of orthostatism, was found in ten cases (19%) in the initial set of measurements on the first day. A cumulative diagnosis of OH after the six BPRO tests was found in 23 cases (43%). The reproducibility of the diagnosis of OH was mild or poor (all kappa values were below 0.47). CONCLUSIONS: BPRO exhibits significant within-day variability in elderly patients. Within-day and day-to-day reproducibility of the diagnosis of OH, based on conventional criteria, were found to be poor.

Statistical analysis of otosclerosis surgery performed by Jean Marquet.

The early and long-term hearing results of 1,681 primary otosclerosis operations performed by the same surgeon, Jean Marquet, were reviewed retrospectively and analyzed with very strict statistical standards. Significantly better short- and long-term results were achieved with the stapedotomy technique compared to total stapedectomy, mainly at the higher frequencies (4 and 8 kHz) important for speech discrimination. Whatever technique was used to open the footplate (micropick, microdrill, or laser), no statistical audiometric difference could be found. The results were equal whether or not the stapedial tendon was preserved. Perioperative problems like pronounced oozing, difficult anatomic relationships, and accidental perilymph aspiration could affect hearing at higher frequencies. The calibrated hole technique was equally as good as conventional oval window sealing in sealing of the fenestra to prevent fistula. The stapedotomy technique was found the safest, having fewer complications.

Persistent stapedial artery: does it prevent successful surgery?

Because of the important function of the embryologic stapedial artery, it is taken for granted by many surgeons that the finding of such a persistent artery in postnatal humans during middle ear surgery should urge maximal caution in order not to damage the artery. Often, discontinuation of the surgery is recommended. Yet this attitude is based on theoretic considerations rather than on any clinical evidence of complications following injury to this vessel. The present paper describes the embryology in relation to this specific aspect and reviews the literature on the persistent stapedial artery, emphasizing the papers dealing with injury to this vessel. In addition, we report 4 cases of persistent stapedial artery from the files of almost 20,000 patients in whom tympanotomy was performed. From all these data we conclude that injury to this artery or even complete section probably does not cause major, if any, postoperative sequelae, and that consequently, middle ear surgery is not necessarily hindered by the presence of this vessel.

[BREV: a rapid clinical scale for cognitive function evaluation in preschool and school-age children]. / BREV: une batterie rapide clinique d'évaluation des fonctions cognitives chez les enfants d'âge scolaire et préscolaire.

BREV, standing for the French "Batterie Rapide d'Evaluation des Fonctions Cognitive", is a rapid test to screen children with disorders of higher functions and to define the patterns of these disorders. We describe here two phases of the validation procedure. The first phase consisted in measuring the internal validity of the scale by testing 500 normal school children free of disability. The validation process provided appropriate values for each of the 18 subtests assessing cognitive functions (oral language, non-verbal abilities, attention and memory, education and memory, educational achievment) in ten age groups from 4 to 8 years. All subtests with the same content for any revealed values which increased significantly with age. Inter-reliability was tested by retesting 70 children. The second phase of validation, comparing BREV results and those from a large classical neuropsychological battery, tested specificity and sensitivity. Each of the BREV subtests were correlated with the similar subtest of the classical battery. Correlations between verbal and non-verbal scores and verbal and performance intellectual quotient (Weschler scale) were very significant. Sensitivity and specificity of BREV were above 75p.100;. This confirms the reliability of this battery for children, with good sensitivity and specificity. BREV is a reliable test, with carefully established norms, appropriate for preschool and school-age children.

[Anti-epilepsy drugs and their use in the elderly]. / Les médicaments de l'épilepsie et leur utilisation chez le sujet âgé.

RISING INCIDENCE AND PREVALENCE: The frequency of epilepsy after the age of 60 years is increasing, a particularly important point in light of the rise in this age group. Incidence is estimated to exceed 100 cases per 100,000 subjects over the age of 60, reaching 160 per 100,000 in subjects aged 80 to 84 years. Prevalence exceeds 7 per 1000 in the 55 to 64 age group and 12 per 1000 in the 85 to 94 age group. CLINICAL FEATURES IN THE ELDERLY: Partial complex seizures are particularly frequent. Some patients experience seizure-related confusion states or slowly regressive neurological deficits. THERAPEUTIC STRATEGY: Excepting acute seizures induced by aggressive cerebral events, treatment should be aimed at the triggering factor. Anti-epilepsy drugs are warranted in patients who experience 2 or more seizures and for whom no amendable triggering factor can be identified. For stroke patients, long-term treatment should be reexamined after the acute phase. DRUG PRESCRIPTION: Benzodiazepines have proven efficacy when the objective is to achieve rapid control of frequent seizures. However, for elderly subjects, the risk of sedation and known adverse effects must be carefully assessed for these drugs. All anti-epilepsy agents are active: choosing the right drug for elderly subjects depends basically on patient tolerance and risk of drug interaction. Special attention should be given to the effect on cognitive function.

[Cochlear implantation, new prosthetic alternative in the management of the profoundly deaf child]. / L'implant cochléaire, nouvelle alternative prothétique dans la prise en charge de l'enfant sourd profond.

Cochlear implants are new medical devices. In contrast to acoustic hearing aids which work by amplification, cochlear implants directly stimulate the hearing neurons via electrode implanted in the cochlear tympanic ramp. They are indicated in case of profound hearing deficiency or in cases of bilateral cophosis, congenital or acquired. Implanted early, they allow deaf children to improve their speech comprehension and their verbal expression considerably, thereby favouring social integration. A concurrent system of support including the use of visual-manual means of communication nevertheless remains vital for the first years. The frequency and duration of such support varies according to the individual.

Petrous bone fractures in children: risk of meningitis, and indication for early Cochlear implant?

The case of a 5 year old boy who had a right petrous bone fracture with right CSF otorrhea and deafness is reported. This child presented, three years after the trauma, a right side otitis media, complicated by meningitis and pneumococcal sepsis, which might have as consequence a left side deafness. The bilateral deafness and the early possibility for cochlear ossification made us decide rapidly on a cochlear implant. Benjamin was then operated for a left side cochlear implant 40 days after contracting meningitis. Two months later, this boy was able to understand a speech without lip reading. Current concepts in the management of petrous bone fractures with CSF otorrhea are reviewed in this report. We also discussed prophylactic attitudes to adopt to reduce the risk of post temporal bone fracture meningitis.