[Suicide attempts with a violent method: Experience of a transdisciplinary psychiatric ward combining psychiatric and somatic care]. / Prise en charge des tentatives de suicide graves : expérience d'un service transdisciplinaire de psychiatrie.

INTRODUCTION: Suicide is the second leading cause of death in young adults. Suicide attempts by violent methods predict later completed suicide and premature mortality. Suicide prevention is a major public health issue in this specific population. The French Student Health Foundation (FSEF) developed a psychiatric ward that includes psychiatric and somatic approaches. This transdisciplinary unit provides mixed psychiatric and rehabilitation treatments for those persons who have attempted suicide and have severe somatic injuries. METHODS: We conducted a retrospective study including all subjects admitted into the transdisciplinary unit from 1st January 2011 to 31 December 2017, after a suicide attempt by jumping from a height, in front of a moving object, or by crashing of a motor vehicle. Data was obtained from the medical and administrative records of the clinic. RESULTS: In total, 215 persons were admitted into the transdisciplinary unit after a suicide attempt by a violent mean. Among them, 91.6% had jumped from a height, 7.4% had jumped in front of a train or a metro and 0.9% had crashed a motor vehicle. They were on average 25.5years old and 50.2% were men. 45.1% had a diagnosis of schizophrenic disorders and 34.4% of mood disorders. A total of 35.6% presented at least one previous suicide attempt, and among them 40.3% had previously attempted suicide with a violent mean. Substance abuse, mostly alcohol and/or cannabis, featured in 40.8% of subject history. The subjects hospitalised in the transdisciplinary unit had multiple, severe injuries: 78.1% had spine fractures, 69.8% had lower limb fractures, 47.9% had pelvic fractures and 43.3% had upper limb fractures. Moreover, 25.5% of them had sacral root damages. The length of stay averaged 184days and varied in a large range (less than a month to more than two years). The Activities of Daily Living scores were higher than 3 (out of a maximum score of 4) reflecting an important need of assistance. These scores decreased significantly during the hospitalisation for dressing, feeding, continence and locomotion but remained high for comportment and communication. At discharge, the physical sequelae were still important: 61% of people hospitalised had pain that required step 2 or 3 analgesics, 44% had analgesics for neuropathic pain, 80% had lower limb impairments, most often with walking limitation, and 26% had continence disorders. The psychotropic treatments at discharge were related to the psychiatric disorders observed and included 42% antidepressants, 63% neuroleptics and 16% mood stabilizers. CONCLUSION: This study highlights the severity of the somatic and psychiatric disorders affecting people who are admitted into this transdisciplinary unit. These subjects who have attempted suicide require particular care with multidisciplinary management in order to promote their rehabilitation, reintegration and prevent a suicide reattempt.

Late Functional Changes Post-Severe Traumatic Brain Injury Are Related to Community Reentry Support: Results From the PariS-TBI Cohort.

OBJECTIVES: To explore late functional changes after a traumatic brain injury and their relation to patients' characteristics and reentry support. DESIGN: Prospective follow-up of an inception cohort of adults with severe traumatic brain injury recruited in 2005-2007 in the Parisian area, France. One and 4-year assessments were performed by trained neuropsychologists. One-to-4-year change in the Glasgow Outcome Scale-Extended defined 3 groups: "improvement," "stability," and "worsening." Relationships between these groups and patients' characteristics were analyzed. RESULTS: Among 504 recruited patients and 245 four-year survivors, 93 participated in both evaluations. Overall Glasgow Outcome Scale-Extended improved by 0.4. Forty percent of the sample improved, 44% were stable, and 16% worsened. Being in a more unfavorable group was related to preinjury alcohol abuse and to higher anxiety and depression at 4 years. Attendance to a specialized community reentry unit was related to higher chances of being in the "improvement" group in univariate analyses and after adjustment for age, time to follow command, preinjury alcohol and occupation, and mood disorders (adjusted odds ratio [OR] = 4.6 [1.1-20]). CONCLUSION: Late functional changes were related to psychosocial variables and to reentry support. The effect of reentry support on late recovery needs to be confirmed by further investigations.

Neuropsychology of traumatic brain injury: An expert overview.

Traumatic brain injury (TBI) is a serious healthcare problem, and this report is a selective review of recent findings on the epidemiology, pathophysiology and neuropsychological impairments following TBI. Patients who survive moderate-to-severe TBI frequently suffer from a wide range of cognitive deficits and behavioral changes due to diffuse axonal injury. These deficits include slowed information-processing and impaired long-term memory, attention, working memory, executive function, social cognition and self-awareness. Mental fatigue is frequently also associated and can exacerbate the consequences of neuropsychological deficits. Personality and behavioral changes can include combinations of impulsivity and apathy. Even mild TBI raises specific problems: while most patients recover within a few weeks or months, a minority of patients may suffer from long-lasting symptoms (post-concussion syndrome). The pathophysiology of such persistent problems remains a subject of debate, but seems to be due to both injury-related and non-injury-related factors.

Predictive factors for 1-year outcome of a cohort of patients with severe traumatic brain injury (TBI): results from the PariS-TBI study.

OBJECTIVES: To assess outcome and predicting factors 1 year after a severe traumatic brain injury (TBI). METHODS: Multi-centre prospective inception cohort study of patients aged 15 or older with a severe TBI in the Parisian area, France. Data were collected prospectively starting the day of injury. One-year evaluation included the relatives-rating of the Dysexecutive Questionnaire (DEX-R), the Glasgow Outcome Scale-Extended (GOSE) and employment. Univariate and multivariate tests were computed. RESULTS: Among 257 survivors, 134 were included (mean age 36 years, 84% men). Good recovery concerned 19%, moderate disability 43% and severe disability 38%. Among patients employed pre-injury, 42% were working, 28% with no job change. DEX-R score was significantly associated with length of education only. Among initial severity measures, only the IMPACT prognostic score was significantly related to GOSE in univariate analyses, while measures relating to early evolution were more significant predictors. In multivariate analyses, independent predictors of GOSE were length of stay in intensive care (LOS), age and education. Independent predictors of employment were LOS and age. CONCLUSIONS: Age, education and injury severity are independent predictors of global disability and return to work 1 year after a severe TBI.

Definition and epidemiology of mild traumatic brain injury.

BACKGROUND/OBJECTIVES: The definition of mild traumatic brain injury (mTBI), also known as concussion, has been a matter of controversy, which makes comparison between studies difficult. Incidence varies greatly from one country to another. The present article reviews definitions and epidemiology. METHODS: Literature review. RESULTS: According to the Mild TBI Committee of the American Congress of Rehabilitation Medicine, revised by the World Health Organization (WHO), mTBI is defined by a Glasgow Coma Scale score between 13 and 15 at 30minutes post-injury, and one or more of the following symptoms: <30min loss of consciousness; <24hours post-traumatic amnesia (PTA); impaired mental state at time of accident (confusion, disorientation, etc.); and/or transient neurological deficit. If a focal lesion is found on computed tomography (CT) or magnetic resonance imaging (MRI), the term "complicated mild TBI" has been proposed. Incidence of mTBI is 200-300/100,000 persons per year for hospitalized patients and probably twice as high if non-hospitalized patients are included. However, a few recent population-based studies reported a much higher rate (>700/100,000). A changing pattern of epidemiology has been found in high-income countries, related to a decrease in road-accident injuries in young adults, while conversely the proportion of falls has increased with population aging. CONCLUSION: Mild TBI is a major public health concern, the epidemiology of which has greatly changed in the last twenty years.

Management of unfavorable outcome after mild traumatic brain injury: Review of physical and cognitive rehabilitation and of psychological care in post-concussive syndrome.

INTRODUCTION: Mild Traumatic Brain Injury (mTBI) is a public health issue with approximately 42 million people worldwide affected yearly. Most patients have a favorable short-term recovery but 10-20% are likely to develop post-concussive syndrome (association of physical, cognitive, and psychological difficulties after injury). Post-concussive syndrome can be associated with Post-Traumatic Stress Disorder (PTSD). There is to date no recommendation on the interventions that could be done to reduce post-concussive syndrome. The present review aims at summarizing the effect of therapeutic education, physical and cognitive rehabilitation and of psychological care in mTBI patients with post-concussive syndrome. METHODS: In the current international literature, we investigated the effects of therapeutic education, physical and cognitive rehabilitation and of psychological care in this population using the Medline database and we discussed the results of these studies. RESULTS: The application of a therapeutic education intervention within 3 months after mTBI has been found appropriate and effective to prevent post-concussion syndrome in several studies but the timeline of this intervention differs among the existing studies. Concerning physical disabilities, several pharmacological, rehabilitative and non-pharmacological techniques have shown some efficacy in reducing headache and vertigo; rTMS seems also promising in this context. The management of fatigue is also crucial and requires a multidisciplinary approach. We did not find any intervention in mTBI patients with post-concussive syndrome suffering from dysosmia and/or dysgueusia. No pharmacological treatment is currently recommended to reduce the cognitive symptoms of post-concussive syndrome after mTBI. Rehabilitation and brain-stimulation techniques have already proven their efficacy to reduce the cognitive impairment in this population. Even if the use of Virtual Reality software seems well tolerated in this population, its efficacy and additional value needs to be demonstrated in larger studies. Concerning the psychological care after mTBI, Cognitive and Behavioral Therapy interventions are the most frequently reported in this population, followed by psychoeducational interventions. PTSD management seems crucial in overall recovery of patients with post-concussive syndrome. CONCLUSION: Many studies have sought to demonstrate the effectiveness of various rehabilitation techniques, including different cognitive rehabilitation programs, technology-assisted rehabilitation, different types of brain stimulation and some pharmacological treatments. However, most of these studies are of a low level of scientific evidence and it would be necessary to carry out well-conducted prospective randomized trials in order to offer an appropriate and effective multidisciplinary management for patients with post-concussive syndrome after mTBI.

[Cognitive rehabilitation]. / La rééducation cognitive.

During these last 30 years, cognitive rehabilitation has accomplished dramatic improvement. In this paper, we review progress in four main domains: the development of pragmatic and ecological approaches in neuropsychological rehabilitation; the development of computerised rehabilitation; rehabilitation of executive functions; cognitive rehabilitation in degenerative dementia. Finally, we present a single-case study, recently published elsewhere, showing the effectiveness of rehabilitation of verbal working memory in a patient with left hemisphere stroke. In addition, future issues for rehabilitation research are presented. The development of bottom-up rehabilitation strategies as well as the use of inter-hemispheric interactions appears as future promising tracks for clinical rehabilitation.

Fatigue and traumatic brain injury.

Fatigue is frequent and disabling in patients with traumatic brain injury (TBI). Its mechanisms are complex and multifactorial. We performed a literature review of reports of the condition using the following key words: brain injury, depression, neuroendocrine dysfunction, and treatment. Five scales have been used to evaluate fatigue in TBI patients: the Fatigue Severity Scale, the visual analog scale (VAS) for fatigue, the Fatigue Impact Scale, the Barrow Neurological Institute (BNI) Fatigue Scale and the Cause of Fatigue (COF) Questionnaire. The BNI Fatigue Scale and the COF Questionnaire have been designed specifically for brain-injured patients. Fatigue is present in 43-73% of patients and is one of the first symptoms for 7% of them. Fatigue does not seem to be significantly related to injury severity not to time since injury. It can be related to mental effort necessary to overcome attention deficit and slowed processing ("coping hypothesis"). It can also be related to sleeping disorders and depression, although the relation between fatigue and depression are debated. Finally, fatigue can also be related to infraclinical pituitary insufficiency (growth hormone insufficiency, hypocorticism). To date, no published study of treatment of fatigue after TBI exists.

[Disabled workers with motor impairments: data from an occupational health service]. / Les travailleurs handicapés par une déficience neuromotrice en milieu ordinaire de travail. Données d'un service interentreprises de santé au travail.

INTRODUCTION: Mediclen is an occupational health service in charge of following-up 36,736 workers (divided among 1770 companies) in 3 cities of an area near Paris. The employment rate of disabled people among the French population is not well known (rough estimate 4.4%), and few studies have reported on the situation of workers with a motor impairment. SUBJECTS AND METHOD: The recent computerization of medical records allowed us to identify 195 workers considered disabled by the French administration (i.e. 0.55% of the 36,736 workers followed up in 2002). Among these, 26 had a motor impairment. RESULTS: Twenty-one neurological disabilities were central and 5 were peripheral or neuromuscular. The workers were 44-years-old. Only two workers had a severe handicap. Companies had to adapt workstations for half of the workers, with the advice of neurologists (7 of 10 advice given) and once a physical medicine doctor. DISCUSSION-CONCLUSION: The integration of people with motor impairments into the world of work is rare and difficult. This practical experience showed the difficulties people with motor impairment face. Close collaboration of physical medicine services with occupational health services is necessary to improve the integration of this population into the world of work.

Neurobehavioral and self-awareness changes after traumatic brain injury: Towards new multidimensional approaches.

Neurobehavioral and self-awareness changes are frequently observed following traumatic brain injury (TBI). These disturbances have been related to negative consequences on functional outcomes, caregiver distress and social reintegration, representing therefore a challenge for clinical research. Some studies have recently been conducted to specifically explore apathetic and impulsive manifestations, as well as self-awareness impairments in patients with TBI. These findings underlined the heterogeneity of clinical manifestations for each behavioral disturbance and the diversity of psychological processes involved. In this context, new multidimensional approaches taking into account the various processes at play have been proposed to better understand and apprehend the complexity and dynamic nature of these problematic behaviors. In addition, the involvement of social and environmental factors as well as premorbid personality traits have increasingly been addressed. These new multidimensional frameworks have the potential to ensure targeted and effective rehabilitation by allowing a better identification and therefore consideration of the various mechanisms involved in the onset of problematic behaviors. In this context, the main objective of this position paper was to demonstrate the interest of multidimensional approaches in the understanding and rehabilitation of problematic behaviors in patients with TBI.

A comprehensive picture of 4-year outcome of severe brain injuries. Results from the PariS-TBI study.

OBJECTIVES: Survivors of severe traumatic brain injury have a great variety of impairments and participation restrictions. Detailed descriptions of their long-term outcome are critical. We aimed to assess brain injury outcome for subjects with traumatic brain injury in terms of the International classification of functioning, disability and health. MATERIALS AND METHODS: Four-year follow-up of an inception cohort of adults with severe traumatic brain injury by using face-to-face interviews with patients and proxies. RESULTS: Among 245 survivors at 4 years, 147 were evaluated (80% male, mean age: 32.5±14.2 years at injury); 46 (32%) presented severe disability, 58 (40%) moderate disability, and 40 (28%) good recovery. Most frequent somatic problems were fatigue, headaches, other pain, and balance. One quarter of subjects had motor impairments. Rates of cognitive complaints ranged from 25 to 68%, the most frequent being memory, irritability, slowness and concentration. With the Hospital Anxiety and Depression Scale, 43% had anxiety and 25% depression. Overall, 79% were independent in daily living activities and 40 to 50% needed help for outdoor or organizational activities on the BICRO-39. Most had regular contacts with relatives or close friends but few contacts with colleagues or new acquaintances. Subjects spent little time in productive activities such as working, studying, looking after children or voluntary work. Quality of life on the QOLIBRI scale was associated with disability level (P<0.0001). CONCLUSION: Management of late brain injury needs to focus on cognitive difficulties, particularly social skills, to enhance patient participation in life.

Functional anatomy of neuropsychological deficits after severe traumatic brain injury.

BACKGROUND: Neurobehavioral disorders after severe traumatic brain injury (TBI) are poorly correlated with focal lesions detected by structural neuroimaging techniques such as CT scan or MRI. OBJECTIVE: To explore the relationships between regional cerebral glucose metabolism at rest, as measured by PET, and neurobehavioral status after severe TBI at the subacute stage. METHODS: Thirteen patients without focal structural lesion on MRI were studied. Neuropsychological assessment included tests of memory, attention and speed of information processing, and executive functions, and a global neurobehavioral assessment. Regional cerebral glucose metabolism at rest was measured with (18F)-fluorodeoxyglucose and PET. RESULTS: A close link was found between cognitive and behavioral disorders and decreased cortical metabolism in prefrontal and cingulate cortex. Tests of memory and executive functions significantly correlated with regional metabolism in the mesial and lateral prefrontal cortex and the cingulate gyrus. Behavioral disorders correlated significantly with mesial prefrontal and cingulate metabolisms. CONCLUSION: These results suggest a predominant role of prefrontal and cingulate dysfunction in cognitive and behavioral disorders of patients with severe traumatic brain injury, even in the absence of focal structural lesion of the brain. Further cognitive functional activation research using PET or functional MRI might help clarify the relative contributions of both areas to dysfunction.

Quality of life in patients with traumatic brain injury-basic issues, assessment and recommendations.

INTRODUCTION: Traumatic brain injuries (TBI) are one of the most common consequences of traffic accidents. Patients with mild, moderate or severe brain injuries suffer from physical, cognitive, behavioral, emotional and social problems. Most of these problems have been a long standing focus amongst practitioners and researchers. Only recently a development has started that took interest in the quality of life outcome of TBI patients. The international members of this consensus meeting reviewed the literature on Quality of Life assessment after TBI and discussed the applicability of different measurements to this specific patient group. TIME POINTS: During the acute phase (T1; < 3 month after trauma) QoL it is difficult to assess due to the reduced consciousness of TBI patients. In the phase of rehabilitation (T2; < one year after trauma) and in the post-rehabilitation phase (T3) repeated assessment of QoL is recommended. INSTRUMENTS: Several generic and disease-specific instruments possibly relevant to TBI patients or specifically developed for this group were assessed according to the existing evidence in the literature. Criteria for the evaluation of these instruments were: feasibility, specificity, validity, comprehensiveness, international availability, existence of norms, and psychometric quality. The cognitive impairment and the existential dimension were not sufficiently considered in most of the reviewed instruments. GROUP CONSENSUS: The family's and relatives' view of the patient's QoL should not be used as a proxy but provides an additional source of information in the acute phase. At T2 and T3, assessment of the patient's quality of life should include a generic as well as a disease specific instrument. Among the generic instruments the SF-36, the EuroQol and the WHO-QoL should be considered. The literature about specific instruments for patients with TBI like the EBIC is scarce. Therefore, the group could hardly give an empirically based recommendation. The need for further investigation on QoL instruments in TBI patients is strongly emphasized.

Slowly progressive apraxia: two case studies.

Two patients with a slowly progressive and severe motor apraxia are presented. In one case, there was only apraxia; in the other there was moderate memory disturbance and a mild decline of global intellectual ability, suggesting a more widespread cognitive dysfunction. In this second case, recognition of the correct use of objects was also severely impaired, suggesting a disturbance of motor knowledge. In both cases, apraxia was asymmetrical, and associated with a contralateral atrophy of the upper parietal cortex, suggesting a differential involvement of separate action systems for each hand.

[Validation of procedures of rehabilitation after cerebrovascular accident]. / Validation des procédures de rééducation après accident vasculaire cérébral.

There are several methodological difficulties in the assessment of the effectiveness of rehabilitation in stroke patients. Obviously, double-blind studies are not possible, and only single-blind procedures can used. It is difficult to control for non specific effects, such as spontaneous recovery, patient's and therapist's motivation, social environment. It is necessary to assess the effect non only at the level of impairments, but also on disability and handicap. However, there are now accumulating data in the literature suggesting that stroke rehabilitation has a significant, although mild, effectiveness. Patients treated in specialized stroke rehabilitation units obtain a better outcome, in terms of independence in daily-life activities, than those treated in general wards. They also have shorter hospitalisation durations and are more frequently able to return home. Treatment effectiveness is related to intensity and duration of rehabilitation, and also to stroke severity. Patients with moderate impairments seem to benefit more from treatment than patients with mild or severe deficits. However, significant improvements can still be obtained in very severe cases, and even late (up to two years) post stroke. Similarly, rehabilitation of cognitive deficits (aphasia and unilateral neglect) has also been found efficient in most studies, even if the beneficial effect is relatively small. Aphasic patients treated by speech therapists improve more than patients treated by non specialized therapists or by family members who received a short training. One limitation of neglect rehabilitation is the inconsistent generalisation of treatment effects to daily-life situations. These data are encouraging but further research is needed to find out what precisely works, and how, in the "black box" of rehabilitation.

[Acute and reversible axonal polyneuropathy in post-leptospirosis]. / Polyneuropathie axonale aiguë et réversible dans les suites d'une leptospirose.

A 53 year old woman presented, one month after an anicteric leptospirosis, an acute, asymmetrical, sensorimotor polyneuropathy involving the lower limbs. Electrophysiological study showed evidence of severe denervation, with normal motor nerve conduction velocities, indicating an axonal degeneration. Neuro-muscular biopsy showed signs of wallerian degeneration and perivascular infiltrates of epineural vessels. She received a corticosteroid therapy during 6 months and there was a nearly complete clinical recovery.

[Pure sensory stroke caused by thalamic hematoma]. / Attaque sensitive pure par hématome thalamique.

A 59-year-old hypertensive patient presented with dysesthesias and a pure sensory deficit involving face, arm and leg on the left side of the body. CT scan and MRI showed a small hematoma in the posterior and lateral part of the right thalamus.

[Double dissociation between unilateral neglect and anosognosia]. / Double dissociation entre négligence unilatérale gauche et anosognosie.

We report two patients presenting with a subacute right hemisphere stroke. These cases demonstrate a double dissociation between unilateral neglect and anosognosia for hemiplegia. The first patient suffered from a severe left hemiplegia associated with severe and persisting unilateral neglect. He appeared fully aware of his motor impairment. The second patient had a severe left hemiplegia, without any major sign of unilateral neglect on clinical tests nor on behavioural assessment. Nevertheless, he presented a severe and sustained anosognosia for hemiplegia. These case reports support the assumption that anosognosia and unilateral neglect, although they are frequently associated, may rely on independent mechanisms.

[Presenting a battery for assessing spatial neglect. Norms and effects of age, educational level, sex, hand and laterality]. / Présentation d'une batterie de dépistage de la négligence spatiale. Normes et effets de l'âge, du niveau d'éducation, du sexe, de la main et de la latéralité.

The aim of this study was to build up a battery for assessing spatial neglect, then to analyse the norms and potential effects of age, education level, sex, hand used, and laterality. It was also to contribute evaluating the pseudoneglect phenomenon described by Heilman, which consists in a tendency of normal subjects to neglect the right peripersonal space. Tasks selected were presented to important groups of normal subjects, most often larger than 450. The battery comprised of a bell cancellation test, scene copy, clock drawing, two line bisection tasks, identification of overlapping figures, text reading, writing task, and the representational task of the France map. For each of them, different variables were selected, especially investigating the difference between performance in the right and the left hemispaces. This study allowed defining the threshold values (percentiles 5 and 95) for deciding of the pathological character of a patient performance. It also showed that the pseudoneglect phenomenon is more obvious in some tasks such as line bisection, and probably also in the representational task of the France map and writing. His importance and at times his side were influenced by the factors we studied, with between tasks differences, but also by the nature of the task to be performed, and especially his verbal component.

[Physiopathology of spasticity and flexion spasms]. / Physiopathologie de la spasticité et des spasmes en flexion.

Spasticity, flexion and extension spasms occur after lesions of motor descending pathways. Three different mechanisms can explain these disorders of tone: pure muscular alterations, segmental synaptic sprouting and liberation of spinal reflex activity. This last mechanism, which is also the most classically described has been studied long ago. Amongst all hypotheses which can explain spasticity (hyperexcitability of alpha motoneuron, gamma motoneuron, or reduction of presynaptic inhibition) reduction of presynaptic inhibition is the only one to have been clearly demonstrated. A new treatment is proposed: intrathecal Baclofen. It seems to act by reducing the excitability of alpha motoneuron.