The mediating role of reflective functioning in the association between childhood trauma and suicide attempt.

BACKGROUND: Childhood trauma is intimately related with suicidal behaviour. Patients who have suffered childhood trauma develop impaired Reflective Functioning (RF), which refers to the capacity to understand ourselves and others in terms of intentional mental states. An improvement in RF has been associated with a reduction in suicidal attempts, but the mediating role of RF between childhood trauma and suicidal behaviour has not been addressed so far. OBJECTIVE: We aim to examine the potential mediating effect of RF among childhood trauma and suicide attempts. METHOD: We included 748 patients who had attempted suicide at least once. They were asked to complete the Reflective Functioning Questionnaire (RFQ-8), the Columbia-Suicide Severity Rating scale (CSSRS), and the Childhood Trauma Questionnaire-Short Form (CTQ-SF). We conducted linear regressions by simple mediating model to examine the role of RF in the indirect association between childhood trauma and the number of suicide attempts. RESULTS: Our results show significant indirect effects through hypo and hypermentalizing between Emotional Abuse (EA) and Sexual Abuse (SA) in childhood and the number of suicide attempts in lifetime. These results indicate that ineffective RF significantly mediates the association between childhood trauma and suicidality. CONCLUSION: This is the first study supporting the mediational role of RF in the relationship between EA and SA, and the number of suicide attempt in lifetime. These findings have important implications for reducing suicide rates and preventing future re-attempts. Further studies analysing this mediating role and focusing efforts on increasing RF-based interventions are required.

Prevalence of clozapine-induced sialorrhea and its effect on quality of life.

RATIONALE: Clozapine has proven to be superior to other antipsychotic drugs in the treatment of schizophrenia but is under-prescribed due to its potentially severe side effects. Clozapine-induced sialorrhea (CIS) is a frequent and extremely uncomfortable side effect, which remains understudied. OBJECTIVES: To examine the prevalence of diurnal and nocturnal CIS in a sample of patients treated with clozapine, and to evaluate its impact on quality of life. METHODS: We conducted a cross-sectional, observational study of 130 patients with schizophrenia spectrum disorders treated with clozapine. The prevalence of CIS was evaluated via specific sialorrhea scales. None of the patients included in the study was receiving a specific treatment for hypersalivation during the study period. Possible associations between sialorrhea and clinical and quality of life variables were analyzed. RESULTS: Of 130 subjects, 120 (92.3%) suffered from CIS. Eighty-one (62.31%) suffered from diurnal CIS, 115 (88.56%) from nocturnal CIS, and 85 (65.38%) suffered from both. Significant positive associations between quality of life and diurnal CIS (B = 0.417; p = 2.1e - 6, R2 = 0.156) and nocturnal CIS (B = 0.411; p = 7.7e - 6, R2 = 0.139) were detected. Thirty per cent of the subjects reported a moderate to severe negative impact of sialorrhea on their quality of life. CONCLUSIONS: The present study suggests that CIS is highly prevalent in patients with schizophrenia and has an important impact on quality of life in one-third of our sample. Therefore, the inclusion of a systematic evaluation and treatment of CIS in standard clinical practice is highly recommended. TRIAL REGISTRATION: Clinical Trials ( https://clinicaltrials.gov ) under reference NCT04197037.

The influence of modifiable cardiovascular risk factors on cognition, functioning, and inflammatory markers in first-episode psychosis: Results from a 2-year follow-up study.

To explore the influence of cardiovascular risk factors (CVRFs) on cognitive symptoms, functional impairment, and systemic inflammatory markers in first-episode psychosis (FEP) patients at baseline and 2-year follow-up. Method: In a sample of 70 FEP patients and 85 age- and sex-matched healthy controls, we assessed nine modifiable CVRFs. All participants were classified into two subgroups according to their CVRF profile: lower (0-1 CVRFs) or higher (≥2 CVRFs). The following outcomes were measured at baseline and 2-year follow-up: cognition; functional outcomes; and white blood cell (WBC) subtype. Adjusted general linear models were conducted to study the effect of diagnosis and CVRF profile on cognition, functioning, WBC, and longitudinal changes in these variables. At baseline, FEP patients with a higher CVRF profile showed a significantly slower performance on the TMT-A test for psychomotor speed and higher lymphocyte levels than patients with a lower CVRF profile. No longitudinal changes were observed in primary outcomes at 2-year follow-up. Among FEP patients with a higher CVRF profile, slower psychomotor speed performance did not correlate with increased lymphocyte levels. Our findings suggest that the cognitive effects of CVRFs manifest early in the course of psychosis, thus highlighting the importance of targeting both CVRFs and cognitive deficits in FEP.

Mental impact of Covid-19 among Spanish healthcare workers. A large longitudinal survey.

AIMS: Longitudinal data on the mental health impact of the coronavirus disease 2019 (Covid-19) pandemic in healthcare workers is limited. We estimated prevalence, incidence and persistence of probable mental disorders in a cohort of Spanish healthcare workers (Covid-19 waves 1 and 2) -and identified associated risk factors. METHODS: 8996 healthcare workers evaluated on 5 May-7 September 2020 (baseline) were invited to a second web-based survey (October-December 2020). Major depressive disorder (PHQ-8 ≥ 10), generalised anxiety disorder (GAD-7 ≥ 10), panic attacks, post-traumatic stress disorder (PCL-5 ≥ 7), and alcohol use disorder (CAGE-AID ≥ 2) were assessed. Distal (pre-pandemic) and proximal (pandemic) risk factors were included. We estimated the incidence of probable mental disorders (among those without disorders at baseline) and persistence (among those with disorders at baseline). Logistic regression of individual-level [odds ratios (OR)] and population-level (population attributable risk proportions) associations were estimated, adjusting by all distal risk factors, health care centre and time of baseline interview. RESULTS: 4809 healthcare workers participated at four months follow-up (cooperation rate = 65.7%; mean = 120 days s.d. = 22 days from baseline assessment). Follow-up prevalence of any disorder was 41.5%, (v. 45.4% at baseline, p < 0.001); incidence, 19.7% (s.e. = 1.6) and persistence, 67.7% (s.e. = 2.3). Proximal factors showing significant bivariate-adjusted associations with incidence included: work-related factors [prioritising Covid-19 patients (OR = 1.62)], stress factors [personal health-related stress (OR = 1.61)], interpersonal stress (OR = 1.53) and financial factors [significant income loss (OR = 1.37)]. Risk factors associated with persistence were largely similar. CONCLUSIONS: Our study indicates that the prevalence of probable mental disorders among Spanish healthcare workers during the second wave of the Covid-19 pandemic was similarly high to that after the first wave. This was in good part due to the persistence of mental disorders detected at the baseline, but with a relevant incidence of about 1 in 5 of HCWs without mental disorders during the first wave of the Covid-19 pandemic. Health-related factors, work-related factors and interpersonal stress are important risks of persistence of mental disorders and of incidence of mental disorders. Adequately addressing these factors might have prevented a considerable amount of mental health impact of the pandemic among this vulnerable population. Addressing health-related stress, work-related factors and interpersonal stress might reduce the prevalence of these disorders substantially. Study registration number: NCT04556565.

Four-month incidence of suicidal thoughts and behaviors among healthcare workers after the first wave of the Spain COVID-19 pandemic.

Healthcare workers (HCW) are at high risk for suicide, yet little is known about the onset of suicidal thoughts and behaviors (STB) in this important segment of the population in conjunction with the COVID-19 pandemic. We conducted a multicenter, prospective cohort study of Spanish HCW active during the COVID-9 pandemic. A total of n = 4809 HCW participated at baseline (May-September 2020; i.e., just after the first wave of the pandemic) and at a four-month follow-up assessment (October-December 2020) using web-based surveys. Logistic regression assessed the individual- and population-level associations of separate proximal (pandemic) risk factors with four-month STB incidence (i.e., 30-day STB among HCW negative for 30-day STB at baseline), each time adjusting for distal (pre-pandemic) factors. STB incidence was estimated at 4.2% (SE = 0.5; n = 1 suicide attempt). Adjusted for distal factors, proximal risk factors most strongly associated with STB incidence were various sources of interpersonal stress (scaled 0-4; odds ratio [OR] range = 1.23-1.57) followed by personal health-related stress and stress related to the health of loved ones (scaled 0-4; OR range 1.30-1.32), and the perceived lack of healthcare center preparedness (scaled 0-4; OR = 1.34). Population-attributable risk proportions for these proximal risk factors were in the range 45.3-57.6%. Other significant risk factors were financial stressors (OR range 1.26-1.81), isolation/quarantine due to COVID-19 (OR = 1.53) and having changed to a specific COVID-19 related work location (OR = 1.72). Among other interventions, our findings call for healthcare systems to implement adequate conflict communication and resolution strategies and to improve family-work balance embedded in organizational justice strategies.

Real-world evidence from a European cohort study of patients with treatment resistant depression: Healthcare resource utilization.

BACKGROUND: Treatment resistant depression (TRD) is diagnosed when patients experiencing a major depressive episode fail to respond to ≥2 treatments. Along with substantial indirect costs, patients with TRD have higher healthcare resource utilization (HCRU) than other patients with depression. However, research on the economic impact of this HCRU, and differences according to response to treatment, is lacking. METHODS: This multicenter, observational study documented HCRU among patients with TRD in European clinical practice initiating new antidepressant treatments. Data regarding access to outpatient consultations and other healthcare resources for the first 6 months, collected using a questionnaire, were analyzed qualitatively according to response and remission status. The economic impact of HCRU, estimated using European costing data, was analyzed quantitatively. RESULTS: Among 411 patients, average HCRU was higher in non-responders, attending five times more general practitioner (GP) consultations and spending longer in hospital (1.7 versus 1.1 days) than responders. Greater differences were observed according to remission status, with non-remitters attending seven times more GP consultations and spending approximately three times longer in hospital (1.7 versus 0.6 days) than remitters. Consequently, the estimated economic impacts of non-responders and non-remitters were significantly greater than those of responders and remitters, respectively. LIMITATIONS: Key limitations are small cohort size, absence of control groups and generalizability to different healthcare systems. CONCLUSION: Patients with TRD, particularly those not achieving remission, have considerable HCRU, with associated economic impact. The costs of unmet TRD treatment needs are thus substantial, and treatment success is fundamental to reduce individual needs and societal costs.

Thirty-day suicidal thoughts and behaviours in the Spanish adult general population during the first wave of the Spain COVID-19 pandemic.

AIMS: To investigate the prevalence of suicidal thoughts and behaviours (STB; i.e. suicidal ideation, plans or attempts) in the Spanish adult general population during the first wave of the Spain coronavirus disease 2019 (COVID-19) pandemic (March-July, 2020), and to investigate the individual- and population-level impact of relevant distal and proximal STB risk factor domains. METHODS: Cross-sectional study design using data from the baseline assessment of an observational cohort study (MIND/COVID project). A nationally representative sample of 3500 non-institutionalised Spanish adults (51.5% female; mean age = 49.6 [s.d. = 17.0]) was taken using dual-frame random digit dialing, stratified for age, sex and geographical area. Professional interviewers carried out computer-assisted telephone interviews (1-30 June 2020). Thirty-day STB was assessed using modified items from the Columbia Suicide Severity Rating Scale. Distal (i.e. pre-pandemic) risk factors included sociodemographic variables, number of physical health conditions and pre-pandemic lifetime mental disorders; proximal (i.e. pandemic) risk factors included current mental disorders and a range of adverse events-experiences related to the pandemic. Logistic regression was used to investigate individual-level associations (odds ratios [OR]) and population-level associations (population attributable risk proportions [PARP]) between risk factors and 30-day STB. All data were weighted using post-stratification survey weights. RESULTS: Estimated prevalence of 30-day STB was 4.5% (1.8% active suicidal ideation; n = 5 [0.1%] suicide attempts). STB was 9.7% among the 34.3% of respondents with pre-pandemic lifetime mental disorders, and 1.8% among the 65.7% without any pre-pandemic lifetime mental disorder. Factors significantly associated with STB were pre-pandemic lifetime mental disorders (total PARP = 49.1%) and current mental disorders (total PARP = 58.4%), i.e. major depressive disorder (OR = 6.0; PARP = 39.2%), generalised anxiety disorder (OR = 5.6; PARP = 36.3%), post-traumatic stress disorder (OR = 4.6; PARP = 26.6%), panic attacks (OR = 6.7; PARP = 36.6%) and alcohol/substance use disorder (OR = 3.3; PARP = 5.9%). Pandemic-related adverse events-experiences associated with STB were lack of social support, interpersonal stress, stress about personal health and about the health of loved ones (PARPs 32.7-42.6%%), and having loved ones infected with COVID-19 (OR = 1.7; PARP = 18.8%). Up to 74.1% of STB is potentially attributable to the joint effects of mental disorders and adverse events-experiences related to the pandemic. CONCLUSIONS: STB at the end of the first wave of the Spain COVID-19 pandemic was high, and large proportions of STB are potentially attributable to mental disorders and adverse events-experiences related to the pandemic, including health-related stress, lack of social support and interpersonal stress. There is an urgent need to allocate resources to increase access to adequate mental healthcare, even in times of healthcare system overload. STUDY REGISTRATION NUMBER: NCT04556565.

Real-world evidence from a European cohort study of patients with treatment resistant depression: Treatment patterns and clinical outcomes.

BACKGROUND: Treatment resistant depression (TRD) characterizes a subgroup of 10-30% of patients with major depressive disorder, and is associated with considerable morbidity and mortality. A consensus treatment for TRD does not exist, which often leads to wide variations in treatment strategies. Real-world studies on treatment patterns and outcomes in TRD patients in Europe are lacking and could help elucidate current treatment strategies and their efficacy. METHODS: This non-interventional cohort study of patients with TRD (defined as treatment failure on ≥2 oral antidepressants given at adequate dose and duration) with moderate to severe depression collected real-world data on treatment patterns and outcomes in several European countries. Patients were started on a new treatment for depression according to routine clinical practice. RESULTS: Among 411 patients enrolled, after 6 months, only 16.7% achieved remission and 73.5% showed no response. At Month 12, while 19.2% achieved remission and 69.2% showed no response, 33.3% of those in remission at Month 6 were no longer in remission. Pharmacological treatments employed were heterogenous; 54 different drugs were recorded at baseline, and the top 5 treatment types according to drug classes accounted for 40.0% of patients. Even though remission rates were very low, at Month 12, 60.0% of patients had not changed treatment since enrolment. CONCLUSIONS: The heterogeneity of treatments highlights a lack of consensus. Moreover, despite low response rates, patients often remained on treatments for substantial periods of time. These data further support existence of an unmet treatment need for TRD patients in Europe.

Real-world evidence from a European cohort study of patients with treatment resistant depression: Baseline patient characteristics.

BACKGROUND: Treatment resistant depression (TRD; failure to respond to ≥2 treatments) affects ~20% of patients with major depressive disorder (MDD). Real-world data could help describe patient characteristics and TRD disease burden, to assess the unmet needs of TRD patients in Europe. METHODS: This observational study collected data from adults with moderate to severe TRD initiating a new treatment for depression, according to local standards of care. At baseline, socio-demographic characteristics, medical history, prior and current treatments were recorded. Disease severity, health-related quality of life (HRQoL), functionality and productivity were assessed. RESULTS: Overall, 411 eligible patients were enrolled across seven European countries. Mean (standard deviation [SD]) patient age was 51.0 (10.8) years; 62.3% were female. Long-term sick leave was reported by 19.0% of patients; 30.2% were unemployed. The mean (SD) duration of the current episode was 2.6 (3.9) years. At baseline, mean (SD) HRQoL scores for EuroQoL 5-dimension 5-level (UK tariff) and EQ-Visual Analog Scale were 0.41 (0.25) and 41.1 (18.7), respectively. The Work Productivity and Activity Impairment questionnaire demonstrated mean (SD) absenteeism of 57.0% (44.9%) and presenteeism of 54.7% (29.5%); mean (SD) overall work impairment was 60.5% (29.9%). LIMITATIONS: Key limitations are small cohort size, absence of a control group and generalizability to countries with different healthcare models. CONCLUSIONS: TRD patients had a high disease burden, low HRQoL and reduced function and productivity, with a substantial proportion unable to work. This demonstrates an unmet treatment need in TRD patients that, if addressed, could reduce the heavy personal and societal burden.

A new detector for the beam energy measurement in proton therapy: a feasibility study.

The proof of concept of a new device, capable of determining in a few seconds the energy of clinical proton beams by measuring the time of flight (ToF) of protons, is presented. The prototype consists of two thin ultra fast silicon detector (UFSD) pads, aligned along the beam direction in a telescope configuration and readout by a digitizer. The method developed for extracting the energy at the isocenter from the measured ToF, validated by Monte Carlo simulations, and the procedure used to calibrate the system are also presented and discussed in detail. The prototype was tested at the Centro Nazionale di Adroterapia Oncologica (CNAO, Pavia, Italy), at several beam energies, covering the entire clinical range, and using different distances between the sensors. The measured beam energies were benchmarked against the nominal CNAO energy values, obtained during the commissioning of the centre from the measured ranges in water. Deviations of few hundreds of keV have been achieved for all considered proton beam energies for distances between the two sensors larger than 60 cm, indicating a sensitivity to the corresponding beam range in water smaller than the clinical tolerance of 1 mm. Moreover, few seconds of irradiation were necessary to collect the required statistics. These preliminary results indicate that a telescope of UFSDs could achieve in a short time the accuracy required for the clinical application and therefore encourage further investigations towards the improvement and the optimization of the present prototype.

Cannabis use influence on peripheral brain-derived neurotrophic factor levels in antipsychotic-naïve first-episode psychosis.

The objective of this study is to determine whether cannabis influences BDNF levels in patients with psychosis (FEP) and healthy volunteers (HV) to help understand the role of BDNF in psychosis. We assessed the association between BDNF and cannabis in a cohort of FEP antipsychotic-naïve patients and HV, whilst controlling for other potential confounding factors. 70 FEP drug-naive patients and 57 HV were recruited. A sociodemographic variable collection, structured clinical interview, weight and height measurement, substance use determination, and blood collection to determine BDNF levels by ELISA analysis were done. In FEP patients, cannabis use was associated with BDNF levels (high cannabis use was associated with lower BDNF levels). Moreover, cannabis use was statistically significantly associated with age (high use of cannabis was associated with younger age). In HV, no relationship between cannabis use and BDNF levels was observed. Otherwise, cannabis use was significantly associated with tobacco use, so that high cannabis users were also high tobacco users. This study showed a different association between cannabis use and BDNF levels in FEP patients compared with HV, particularly, with high doses of cannabis. These findings may help understand the deleterious effects of cannabis in some vulnerable individuals, as well as discrepancies in the literature.

Primer ensayo clínico empleando la estimulación cerebral profunda en pacientes con esquizofrenia resistente / Deep brain stimulation in treatment resistant schizophrenia: A pilot randomized cross-over clinical trial

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Extensively drug-resistant Pseudomonas Aeruginosa outbreak in a burn unit: management and solutions.

Infections are still the main cause of mortality in burn patients. Multidrug resistant bacteria can cause outbreaks in critical care and burn units. We describe an outbreak of infection by extensively drug-resistant Pseudomonas aeruginosa in the Burn Unit of a University Hospital in Barcelona (Spain) between April and July 2016. A descriptive study of all cases, a bacterial colonization screening of all admitted patients and a microbiological environmental study were performed in order to detect a possible common focus. Contact isolation and cohortization of healthcare workers of all infected or colonized patients were applied. Environmental control measures were instituted for possible sources of infection. The outbreak was caused by a strain of P. aeruginosa only sensitive to colistin. Ten patients were infected or colonized and two of them died. The same strain was detected in several taps and drains in different rooms of the Unit. After applying control measures, changing faucets and drains, carrying out thermal disinfection of the hot water installation of the unit, disinfecting the rooms with ultraviolet radiation and placing antibacterial filtration devices in all the taps among other measures, an effective control of the outbreak was achieved.

Les infections sont toujours une cause majeure de mortalité chez les brûlés. Des épidémies à bactéries multirésistantes (BMR) dans les CTB sont régulièrement rapportées. Nous décrivons une épidémie due à Pseudomonas æruginosa BMR, sensible uniquement à la colimycine, survenue dans le CTB d'un hôpital universitaire de Barcelone entre avril et juillet 2016. Elle a touché 10 patients dont 2 sont morts. Une étude de chaque cas, un dépistage chez tous les entrants et une étude environnementale ont été réalisées, afin de trouver d'éventuelles similitudes. Un isolement contact et un cohorting ont été mis en place. Des mesures de contrôle de l'environnement ont été implémentées. La souche incriminée a été retrouvée dans plusieurs robinets et siphons du service. Cette épidémie a été résolue après, outre les mesures précitées, changement des robinets et des siphons (avec mise en place d'ultrafiltres sur les robinets), choc thermique du réseau d'adduction d'eau, désinfection terminale UV des chambres.

Spanish translation and analysis of the metric properties of inpatient satisfaction scale in psychiatry: The Satispsy-22-E.

The Satispsy-22 scale is an instrument created for the specific evaluation of psychiatric inpatient satisfaction. Therefore, the study aims to carry out the Satispsy-22 scientific translation to Spanish and to learn its psychometric properties. The Satipsy-22-E was administered to discharged patients from four units of acute psychiatric admission, a unit of dual pathology and two units of subacute psychiatric admission (N = 268). Cronbach's alpha was 0.886, which can be interpreted as good internal reliability. All the dimensions showed a good internal consistency with scores from 0.722 to 0.919. Test-retest offered scores of 0.752-0.951 showing good stability. Confirmatory factor analysis showed that all elements load in the estimated dimensions of the original scale and these were significant and the adjustment measures showed, in general, a rather good adjustment, Root Mean Square Error (RMSE) showed that the error between observations and actual data is small and acceptable. Satispsy-22-E is a specific scale in Spanish language for the assessment of psychiatric inpatient satisfaction. It is an easy to use tool that offers good psychometric properties. The availability of a validated survey in Spanish may help to improve the care provided by psychiatric wards in Spanish-speaking countries.

A study on the bioequivalence of lithium and valproate salivary and blood levels in the treatment of bipolar disorder.

Lithium (Li) and valproate (VPA) are used in the treatment of bipolar disorder (BD), with narrow therapeutic window requiring periodic control of serum levels. This prevents intoxication, lack of efficacy due to low serum concentrations, and allows monitoring adherence. We aimed at evaluating the bioequivalence of salivary and blood levels of LI or VPA in a sample of adult BD patients. Secondarily, lithium bioequivalence was evaluated across different patients' lifespans. BD patients treated with either Li or VPA underwent contemporary standard serum and salivary measurements. Blood levels of both drugs were taken according to standard procedures. Li salivary levels were performed by an adapted potentiometric method on the AVL9180 electrolyte analyzer. VPA salivary levels were taken with an immune-assay method with turbidimetric inhibition. A total of 50 patients (38 on Li, 12 on VPA) were enrolled. Blood-saliva bioequivalence for VPA was not found due to a high variability in salivary measures. Li measures resulted in a high correlation (r=0.767, p<0.001), showing no partial correlation with age (r=0.147, p=0.380). Li salivary test is a reliable method of measuring Li availability and is equivalent to serum levels. Potential advantages of Li salivary testing are its non-invasive nature and the possibility of doing the test during the usual appointment with the psychiatrist.

Functional reconstruction of acutely burnt achilles tendon with composite anterolateral thigh flap with fascia lata: a case report.

Soft tissue defects in the postero-inferior aspect of the leg are still challenging, especially when they affect the Achilles tendon due to its important functional involvement in the normal movement of the ankle. Dorsiflexion and flexion may be affected if proper reconstruction is not achieved, thus limiting daily activities such as walking, climbing stairs or running. Several techniques, including local or regional flaps, combinations of tendon substitutes with free muscular or fasciocutaneous flaps, and free composite flaps with tendon have been described for the reconstruction of complex defects caused by burn sequelae, tumors, trauma, chronic ulcers, etc. The gold standard treatment for moderate to large defects is the anterolateral thigh (ALT) flap with vascularized fascia lata. The ALT flap is reliable because of a long vascular pedicle and a large donor area. Moreover, the fascia lata mimics the Achilles tendon perfectly when rolled on itself. The aim of this article is to present the application of this technique for the first time in a case of an acute burn. The timing of reconstruction with free flaps is critical in acute burns. In our case, it was performed on the 24th day post-burn and no microsurgical complications appeared. More than six months after surgery, the patient showed a normal gait, was able to lift his own weight against gravity and no complications were detected in the donor area.

Les pertes de substance des parties molles de la région postéro inférieure de jambe constituent un problème majeur, surtout quand elles intéressent le tendon d'Achille, à cause de son importante implication dans les mouvements normaux de la cheville. La dorsiflexion et la flexion peuvent être affectées si une réparation correcte n'est pas réalisée, car elle limite les activités journalières telles que la marche, la montée d'escaliers, ou la course. Plusieurs techniques incluant les lambeaux locaux et régionaux, l'association de substituts tendineux avec des lambeaux libres musculaires ou fascio cutanés, et les lambeaux libres composites avec tendon ont été décrits pour la reconstruction des pertes de substances complexes en rapport avec séquelles de brûlures, tumeurs, traumatismes, ulcères chroniques etc. Le traitement de référence pour des pertes de substances modérées ou importantes est constitué par le lambeau antero latéral de cuisse avec fascia lata vascularisé. Ce lambeau est sûr, du fait du long pédicule vasculaire et de l'importance de la surface de la zone donneuse. Cependant, le fascia lata imite parfaitement le tendon d'Achille, que s'il est roulé sur lui-même. Le but de cet article est de présenter une application de cette technique pour la première fois dans un cas de brûlures en urgence. Le moment de la reconstruction par lambeaux libres est discuté dans les brûlures. Dans notre observation, il a été réalisé au cours du 24 e jour après la brûlure et sans complications micro chirurgicales. Plus de six mois après la chirurgie, le patient affiche une démarche normale, il est capable de se lever tout seul et aucune complication n'est apparue au niveau de la zone donneuse.

Attempted and completed suicide: not what we expected?

BACKGROUND: Suicide attempters and suicide completers are two overlapping but distinct suicide populations. This study aims to present a more accurate characterization by comparing populations of suicide attempters and completers from the same geographical area. METHODS: Samples and procedure: All cases of attempted suicide treated at the emergency room of the Corporacio Sanitària i Universitària Tauli Parc de Sabadell in 2008 (n=312) were compared with all completed suicides recorded in the same geographical area from 2008 to 2011 (n=86). Hospital and primary care records were reviewed for sociodemographic and clinical variables. STATISTICAL ANALYSIS: Chi-square, ANOVA, and Mann-Whitney U tests were used to identify characteristics related to suicide completion. RESULTS: Compared to suicide attempters, suicide completers were more likely to be male (73.3% vs. 37.8%; p<0.001), pensioners (73.7% vs. 23.4%; p<0.001), and people living alone (31.8% vs. 11.4%; p=0.006). Suicide completers more frequently presented somatic problems (71.7 vs. 15.7; p<0.001), Major Depressive Disorder (54.7% vs. 27.9%; p<0.001), and made use of more lethal methods (74.1 vs. 1.9; p<0.001). Suicide completers were more likely to have been followed by a primary care provider (50.0% vs. 16.0%; p<0.001). 92.3% of the suicides committed were completed during the first or second attempt. LIMITATIONS: Suicide completers were not evaluated using the psychological autopsy method. CONCLUSIONS: Despite presenting a profile of greater social and clinical severity, suicide completers are less likely to be followed by Mental Health Services than suicide attempters. Current prevention programs should be tailored to the specific profile of suicide completers.

Different levels of lack of improvement at 4 weeks of escitalopram treatment as predictors of poor 8-week outcome in MDD.

BACKGROUND: Several post-hoc studies have shown that lack of early improvement reduces the chance of later response or remission. This post-hoc analysis evaluates different cut-off points of non-improvement at 4 weeks of escitalopram treatment to predict 8-week non-response and non-remission. METHOD: This study consisted of MDD patients with an absence of improvement (<30% reduction in baseline score of the HAMD-17) at Week 4 of escitalopram treatment (10mg/day) that continued escitalopram treatment (10-20mg/day) for a further 4-week period (n=251). Predictive, sensitivity and specificity values for the several definitions of non-improvement (≤ 25%, ≤ 20% and ≤ 15% reduction in the HAMD-17 baseline total score) at 4 weeks were calculated. RESULTS: Overall, 70.1% (176/251) of patients did not achieve response at Week 8 and 84.5% (212/251) did not achieve remission. The predictive value for non-response was high (71.4-74.3%) for all cut-off points of non-improvement tested. The respective values for non-remission were placed between 85.0% and 87.2%. LIMITATIONS: This was a post-hoc subgroup analysis. The only drug assessed was escitalopram. CONCLUSIONS: Our data indicate that an absence of improvement, <30% reduction in the HAMD-17, after 4 weeks of escitalopram treatment should prompt clinicians to consider a change in treatment strategy. Similar findings were previously reported for other antidepressants.

Radioterapia de intensidad modulada (imrt) / Intensity modulation radiation therapy (imrt)

La radioterapia es un tratamiento efectivo en el manejo del cáncer. Es responsable de mejorar significativamente el control locorregional, la supervivencia global y la calidad de vida en múltiples tumores. Históricamente, sin embargo, sus complicaciones agudas y crónicas han reducido estos beneficios. La incorporación de la computación a la radioterapia ha permitido el desarrollo de diversas técnicas de tratamiento, incluyendo la radioterapia conformada 3D (3D-CRT) y la intensidad modulada (IMRT). Éstas permiten aumentar la dosis tumoral protegiendo los tejidos sanos, con un potencial aumento en el control del tumor y reducción de las complicaciones agudas y crónicas asociadas. Múltiples estudios prospectivos y retrospectivos han evaluado los beneficios de la IMRT en distintos tumores primarios. Hasta ahora sus principales indicaciones son cáncer de próstata y de cabeza y cuello. En otras localizaciones se han obtenido mejorías dosimétricas significativas. Se requiere mayor seguimiento para conocer los resultados clínicos tardíos de esta tecnología.

Radiation therapy is an effective treatment in cancer management. It is responsible for significant improvements in local/regional control, overall and cause-specific survival and better quality of life in many tumors. Nevertheless, in the past, acute and chronic radiation toxicity has reduced this benefits. The introduction of computer technologies to radiotherapy has allowed the development of various planning and treatment techniques, including 3D conformal radiotherapy (3D-CRT) and intensity modulation (IMRT), permiting to escalate tumor doses while protecting healthy tissues. This can improve tumor control and reduce acute and late complication rates associated with radiotherapy. Multiple prospective and retrospective studies have evaluated the benefits of IMRT in different primary tumors. Their main indications are head and neck and prostate cancer. In other locations, a significant dosimetric improvements of IMRT have been found, but longer follow-up is required to identify long term effects.

[Urodynamic study in the female urinary incontinence evaluation, with the new MoniTorr MR system (non-multichannel urodynamic with urethral retro-resistance pressure measure). Experience with 100 patients]. / Estudio urodinámico en la evaluación de la incontinencia urinaria femenina, con el nuevo sistema MoniTorr MR (urodinamia monocanal con medición de presión de retro-resistencia uretral). Experiencia con 100 pacientes.

OBJECTIVE: To compare the clinical diagnosis of the urinary incontinence with the results of LPP and URP obtained by non-multichannel urodynamic. To evaluate the tolerance of the patients to this examination. PATIENT AND METHOD: Between August and December 2006, 100 urodynamics were made in patients with clinical diagnosis of urinary incontinence, in the Urogynecology Unit of Clinica Las Condes. The clinical diagnosis was compared with the urodynamic results. A subjective tolerance scale was applied (0 was greater tolerance and 10 was maximum discomfort). RESULTS: In 66 patients with clinical diagnosis of IUS, the urodynamic registered 10 Type 0, 2 (I), 23 (II), 1 (III), 17 (II+III), 1 hyperactive detrusor, 5 (0+ hyperactive detrusor). 3 (II+hyperactive detrusor) and 4 (II+III+hyperactive detrusor). In 15 with Mixed urinary incontinence, the urodynamic showed 6 (Type 0), 2 (II), 2 (II+III), 3 hyperactive detrusor, 1 (II+hyperactive detrusor) and 1 (III+hyperactive detrusor). In 16 patients with urgency incontinence, urodynamic showed 2 normal, 4 (II+III), 7 hyperactive detrusor, 1 (II+hyperactive detrusor) and 2 (II+III+hyperactive detrusor). In 3 patients (two vaginal cuff prolapse and one cistocele, degree IV POP-Q) the urodynamic was indicated in the pre-surgery study considering a great potentially incontinence after correction. Respectively, the patients presented: IUS type III+hyperactive detrusor, IUS type II+III and one normal. All patients expressed 2 and 3 degree tolerance (subjective scale: 1 major tolerance and 10 a minor tolerance). CONCLUSIONS: The MoniTorr MR urodynamic is a complementary examination very useful in the study of the urinary incontinence. It allows planning the solution adapted for each case and has a high degree of tolerance in the patients.