[Mindfulness-based interventions in obsessive-compulsive disorder: Mechanisms of action and presentation of a pilot study]. / Les interventions basées sur la pleine conscience dans le trouble obsessionnel compulsif : mécanismes d'action et présentation d'une étude pilote.

Obsessive-compulsive disorder (OCD) is a frequent and severe disease, potentially inducing a major impairment for the patient and burden for their family. Recent research in psychiatry and neuroscience have led to better comprehension of the disease's mechanisms and helped to improve its treatment. However, a large proportion of patients have refractory symptoms, including for traditional cognitive and behavioral therapy by exposure and response prevention (ERP), leading clinicians to look for new treatments. Mindfulness-based interventions (MBI) are a new type of approach, initially based on Buddhist meditation, which aims to provide better consciousness of the present moment. It has been successfully developed in some psychiatric diseases and other general medical conditions such as chronic pain. The two main programs using mindfulness meditation, Mindfulness-based stress reduction (MBSR) and Mindfulness-based cognitive therapy (MBCT), have shown effectiveness for the reduction of depressive and anxiety symptoms and relapses of depressive episodes in unipolar depression. It has no side effects and is well tolerated by patients. Its action relies on the specific correction of cognitive deficits in attention, emotion regulation and executive functions which are shared by OCD, GAD and depression. For OCD, we make the hypothesis that Mindfulness-Based Interventions could reduce the cognitive bias specifically existing in this pathology, such as dysfunctional beliefs, and therefore improve the symptoms. This article first reviews the existing literature on clinical trials involving Mindfulness-Based Interventions in OCD which comprises a small number of clinical studies based on very different types of protocols. At this time, and due to the lack of gold-standard studies with a large number of patients, no proof of the efficiency of mindfulness-based interventions in OCD has been shown. In a second section, following our hypothesis on the mechanisms of specific and non-specific action of this therapy in OCD, we propose a cognitive model of mindfulness-based therapy action in OCD involving the correction of OCD's cognitive bias. In this model, mindfulness-based therapy is supposed to treat specifically the cognitive aspects of the disease, while ERP is focused on its behavioral part. Then we present a clinical study aiming to prove the feasibility and the interest of the use of mindfulness in OCD, carried out in two different clinical centers. One of them used MBCT while the second used MBSR. Its results show the feasibility of mindfulness-based therapy in OCD patients and tend to prove that it could be more effective in young patients suffering from less severe forms of OCD. In parallel, attention tests and fMRI scans were done at the beginning and at the end of the therapy. Their results will be published separately. We also discuss the putative role of a specific form of MBCT adapted for OCD, specifically for its benefits in psychoeducation, which could reduce the dysfunctional beliefs present in OCD patients. Finally, we propose a therapeutic strategy in which the MBCT could complement the classical ERP therapy, as a "maintenance" treatment, aiming to extend the relapse of OCD symptoms. This article is a step further in the use of mindfulness-based therapy for OCD which could be added to the existing treatments reducing the patient's symptoms and improving their quality of life.

[Repair in rheumatic mitral valve insufficiency]. / Plastica della valvola mitrale nell'insufficienza di natura reumatica.

OBJECTIVES: Emerging evidence indicates that etiology plays an essential role in the results of mitral valve repair. In this study, we examined the long-term performance of this procedure in 61 consecutive patients with pure rheumatic mitral insufficiency. PATIENTS: Patient ages ranged from 4 to 74 years (mean: 51.7 +/- 16). Preoperatively, 94% of the patients were in NYHA class II or III. RESULTS: There was no hospital mortality. According to actuarial methods 94.1% of the patients were alive 7 years postoperatively and 83.3% were reoperation free. Freedom from reoperation was significantly higher in patients who received a prosthetic ring than in those who had other types of annuloplasty (96.7% vs 59.3%; p = 0.001). As opposed to the literature, in our series there was no relationship between valve failure and age at the time of reoperation. There were only two cases of thromboembolism and one of infective endocarditis. CONCLUSIONS: This study confirms that mitral valve reconstruction in rheumatic valve insufficiency can yield satisfactory long-term clinical results, although they are less than optimum compared with those obtained in patients with degenerative disease. Favourable results depend on routine use of a prosthetic ring as well as adequate patient selection. Attention should be focused on improved detection and suppression of rheumatic activity at the time of operation.

Influence of type and severity of pure forms of age-related cataract on visual acuity and contrast sensitivity. Italian American Cataract Study Group.

PURPOSE: To compare the relationship between logMAR visual acuity (VA) and cataract severity and between contrast sensitivity (CS) and cataract severity in pure types of age-related lens opacities. METHODS: Analysis included patients followed in the ongoing Italian-American Study of the Natural History of Age-Related Cataract. Lens opacities were classified and graded according to the Lens Opacities Classification System II (LOCS II). Visual acuity was measured with the Early Treatment Diabetic Retinopathy Study Chart. Contrast sensitivity was measured with the Pelli-Robson chart. RESULTS: Data from 1,076 eyes were used for the analysis (366 clear lenses; 550, 124, and 36 eyes with cortical, nuclear and posterior subcapsular cataract, respectively). In age-adjusted analyses, increasing severity of all three cataract types was associated with progressively higher logMAR VA, which translates into poorer acuity, and lower CS scores. For both VA and CS, the effect of increasing severity was greatest for nuclear and least for cortical opacities. After adjusting for age and VA, CS scores were no longer associated with cataract type and severity, with the exception of advanced cortical opacities. CONCLUSIONS: Increased cataract severity, as determined by LOCS II grading, is strongly associated with both VA and CS scores. Contrast sensitivity scores obtained from testing at low spatial frequency do not seem to offer additional information over standard VA testing in early cortical and posterior subcapsular opacities nor in nuclear cataracts.

The effect of cataract severity and morphology on the reliability of the Lens Opacities Classification System II (LOCS II).

Data collected from 3646 eyes in the Italian-American Natural History Study of Age-Related Cataract were used to investigate whether the reliability of the Lens Opacities Classification System II (LOCS II) by the severity of the opacity that is being graded or is influenced by the presence and severity of coexisting opacities. Reliability was assessed by comparing the slit-lamp gradings of two clinical examiners (346 eyes) and the gradings performed at the slit lamp with gradings of photographs (3646 eyes). The severity of cortical and nuclear opacities did not affect the reproducibility of slit-lamp gradings, but clinical grading of posterior subcapsular opacities became more reliable as the severity of the posterior subcapsular opacities increased. More advanced coexisting opacities decreased the agreement in the slit-lamp diagnosis of nuclear, but not cortical or posterior subcapsular, opacities. Comparisons of clinical and photographic gradings showed very good to excellent agreement for nuclear and cortical opacities, regardless of the severity of the specific opacity or the severity of the coexisting opacities. Agreement in diagnosing posterior subcapsular opacities was decreased in eyes with milder posterior subcapsular opacities and in eyes with more severe coexisting nuclear and/or cortical opacities. The effect of the severity of the opacity being graded and the severity of coexisting opacities on the reliability of the LOCS II must be considered in studies that use the system to classify and grade cataracts.

Distribution of lens opacities in the Italian-American Case-Control Study of Age-Related Cataract. The Italian-American Study Group.

The Lens Opacities Classification System I (LOCS I) was used to classify lens opacities in the clinic-based Italian-American Case-Control Study of Age-Related Cataract. Data on the distribution of cataract types among the 1008 patients (age range, 45-79 years) are presented. A single type of cataract was found in 65% of all cases in whom both lenses could be graded. Among all patients and among patients with only one type of cataract, cortical opacities occurred most frequently and posterior subcapsular opacities least frequently. In patients with bilateral cataracts there was a high degree of concordance of cataract type and severity. The high degree of concordance of cataract type between eyes and the decreasing prevalence of unilateral cataract with increasing age suggest that patients with unilateral cataract are at high risk of developing the same opacity in the fellow eye. Cortical cataracts were found more frequently in women, and in patients with unilateral cataract, the left eye was more frequently affected. Clinic-based data on the distribution of cataract may be of assistance in planning future clinical studies of cataract.

An independent evaluation of the Lens Opacities Classification System II (LOCS II). The Italian-American Cataract Study Group.

The Lens Opacities Classification System II (LOCS II) has been offered for use in clinical studies of cataract. The system uses slit lamp and retroillumination photographic standards to grade lens opacities into classes of increasing severity. The authors evaluated the reproducibility and validity of LOCS II before its possible use in a natural history study of age-related cataract. The authors found excellent inter- and intraobserver reproducibility when the LOCS II standard photographs were used for clinical or photographic gradings of cataract. There was a tendency to underestimate posterior subcapsular cataracts on photographic gradings compared with slit-lamp gradings. The accuracy of the photographic gradings of posterior subcapsular opacities tended to decrease as the severity of coexisting opacities increased.

Preliminary evaluation of a simple photographic cataract classification for epidemiological surveys.

A preliminary evaluation of the agreement between clinical and photographic cataract classification and its reproducibility by utilizing a very simple classification system is presented. Photographic classification was based on color Zeiss 75-SL transparencies. Results indicate that photo-derived cataract classification based on slitlamp photographs has good validity for nuclear opacities but tends to underestimate posterior subcapsular cataracts.

86-Rb efflux in normal and cataractous human lenses.

86Rb efflux has been studied in normal lenses and in human senile cataracts. The rate constant (Ki) of the efflux gradually increases in cataractous lenses with progression of lens damage. Efflux experiments run in the presence of BaC12 suggest that a progressive activation of BaC12 inhibitable efflux routes occurs in cataractous lenses. In the final stages of opacification the ineffectiveness of BaC12 enriched or Ca++ free media on the efflux suggests that a direct disruption of the lens membranes has occurred.