Infant's triangular communication in "two for one" versus "two against one" family triangles: Case illustrations

Infants use their social competence very early to communicate not only in dyads but also in triads, in particular in the triangle they form with their mother and father. The development of this triangular communication is largely shaped by the ways the parents support or undermine each other in relation to their child. Whereas triangular communication is facilitated in "two for one" alliances, it is recruited in the service of regulating the parents' conflicts in "two against one" coalitions. These processes are manifest in toddlerhood and may be traced back to the coparenting alliance in formation during pregnancy.

Intravenous immunoglobulin for treatment of mild-to-moderate Alzheimer's disease: a phase 2, randomised, double-blind, placebo-controlled, dose-finding trial.

BACKGROUND: Three small trials suggest that intravenous immunoglobulin can affect biomarkers and symptoms of mild-to-moderate Alzheimer's disease. We tested the safety, effective dose, and infusion interval of intravenous immunoglobulin in such patients. METHODS: We did a multicentre, placebo-controlled phase 2 trial at seven sites in the USA and five in Germany. Participants with probable Alzheimer's disease aged 50-85 years were randomly assigned (by a computer-generated randomisation sequence, with block sizes of eight) to infusions every 4 weeks (0·2, 0·5, or 0·8 g intravenous immunoglobulin per kg bodyweight, or placebo) or infusions every 2 weeks (0·1, 0·25, or 0·4 g/kg, or placebo). Patients, caregivers, investigators assessing outcomes, and staff at imaging facilities and the clinical research organisation were masked to treatment allocation, but dispensing pharmacists, the statistician, and the person responsible for final PET analyses were not. Treatment was masked with opaque pouches and infusion lines. The primary endpoint was median area under the curve (AUC) of plasma amyloid β (Aβ)(1-40) between the last infusion and the final visit (2 weeks or 4 weeks depending on infusion interval) in the intention-to-treat population. The trial is registered at ClinicalTrials.gov (NCT00812565) and controlled-trials.com (ISRCTN64846759). FINDINGS: 89 patients were assessed for eligibility, of whom 58 were enrolled and 55 included in the primary analysis. Median AUC of plasma Aβ(1-40) was not significantly different for intravenous immunoglobulin compared with placebo for five of the six intervention groups (-18·0 [range -1347·0 to 1068·5] for 0·2 g/kg, -364·3 [-5834·5 to 1953·5] for 0·5 g/kg, and -351·8 [-1084·0 to 936·5] for 0·8 g/kg every 4 weeks vs -116·3 [-1379·0 to 5266·0] for placebo; and -13·8 [-1729·0 to 307·0] for 0·1 g/kg, and -32·5 [-1102·5 to 451·5] for 0·25 g/kg every 2 weeks vs 159·5 [51·5 to 303·0] for placebo; p>0·05 for all). The difference in median AUC of plasma Aβ(1-40) between the 0·4 g/kg every 2 weeks group (47·0 [range -341·0 to 72·5]) and the placebo group was significant (p=0·0216). 25 of 42 (60%) patients in the intervention group versus nine of 14 (64%) receiving placebo had an adverse event. Four of 42 (10%) patients in the intravenous immunoglobulin group versus four of 14 (29%) receiving placebo had a serious adverse event, including one stroke in the intervention group. INTERPRETATION: Intravenous immunoglobulin may have an acceptable safety profile. Our results did not accord with those from previous studies. Longer trials with greater power are needed to assess the cognitive and functional effects of intravenous immunoglobulin in patients with Alzheimer's disease.

Tuberculose miliaire chez une personne âgée: diagnostic inattendu à l'autopsie [Miliary tuberculosis: unexpected autopsy finding in an elderly person].

Miliary tuberculosis is a rare disease that is difficult to diagnose because of its non-specific presentation. It should be suspected in elderly patients who complaint of failure to thrive, unexplained fatigue and weight loss. Using a clinical situation where the diagnosis was made only at autopsy, we briefly review the epidemiology of miliary tuberculosis and propose recommendations for the diagnosis and the prophylaxis of latent tuberculosis. Finally, we discuss criteria to perform epidemiological investigations among close contacts in this situation.

A methodology to estimate the potential to move inpatient to one day surgery.

BACKGROUND: The proportion of surgery performed as a day case varies greatly between countries. Low rates suggest a large growth potential in many countries. Measuring the potential development of one day surgery should be grounded on a comprehensive list of eligible procedures, based on a priori criteria, independent of local practices. We propose an algorithmic method, using only routinely available hospital data to identify surgical hospitalizations that could have been performed as one day treatment. METHODS: Moving inpatient surgery to one day surgery was considered feasible if at least one surgical intervention was eligible for one day surgery and if none of the following criteria were present: intervention or affection requiring an inpatient stay, patient transferred or died, and length of stay greater than four days. The eligibility of a procedure to be treated as a day case was mainly established on three a priori criteria: surgical access (endoscopic or not), the invasiveness of the procedure and the size of the operated organ. Few overrides of these criteria occurred when procedures were associated with risk of immediate complications, slow physiological recovery or pain treatment requiring hospital infrastructure. The algorithm was applied to a random sample of one million inpatient US stays and more than 600 thousand Swiss inpatient stays, in the year 2002. RESULTS: The validity of our method was demonstrated by the few discrepancies between the a priori criteria based list of eligible procedures, and a state list used for reimbursement purposes, the low proportion of hospitalizations eligible for one day care found in the US sample (4.9 versus 19.4% in the Swiss sample), and the distribution of the elective procedures found eligible in Swiss hospitals, well supported by the literature. There were large variations of the proportion of candidates for one day surgery among elective surgical hospitalizations between Swiss hospitals (3 to 45.3%). CONCLUSION: The proposed approach allows the monitoring of the proportion of inpatient stay candidates for one day surgery. It could be used for infrastructure planning, resources negotiation and the surveillance of appropriate resource utilization.

Traumatismes précoces et réponses de stress, leur association aves la santé mentale, l'attachement et l'ocytocine

Lorsqu'un individu est confronté à une situation stressante, une des réponses les plus saillantes est l'activation de l'axe HPA, caractérisée par le déclenchement d'un taux élevé de glucocorticoïdes dans le sang. De manière générale, cette réponse hormonale est adaptative et elle a pour but la mobilisation des ressources physiques et cognitives de l'individu pour une action spécifique (Axelrod & Reisine, 1984; Chrousos & Gold, 1992; N. M. Kaplan, 1988; McEwen, 2004). Cependant, lorsque une personne est confrontée très tôt dans son développement, et de manière répétée, à des situations de stress, cette réponse physiologique peut s'altérer, devenir inadaptée (Anand, 1993; Bremner et al., 1995; Meaney et al., 1996; Mirescu, Peters, & Gould, 2004; Plotsky & Meaney, 1993; Sapolsky, 2000) et être associée à des troubles cognitifs (McEwen & Sapolsky, 1995) et émotionnels (McEwen, 2000). A l'âge adulte, le résultat de ces altérations psychoneuroendocriniennes se traduit au cours de l'activation de l'axe HPA et elles sont visibles lors de situations de stress moins intenses (Graham, Heim, Goodman, Miller, & Nemeroff, 1999; Mirescu et al., 2004; Stam, Bruijnzeel, & Wiegant, 2000; A. Taylor, Fisk, & Glover, 2000). La dysregulation de l'axe HPA semble représenter un facteur de vulnérabilité lié à des dysfonctionnements psychiques et physiologiques chez les adultes (Heim, Ehlert, & Hellhammer, 2000; Heim & Nemeroff, 1999; Heim, Newport, Mletzko, Miller, & Hemeroff, 2008). Cependant, des facteurs de protection peuvent influencer à leur tour ces vulnérabilités. La littérature, basée sur des études translationnelles (animaux, humains), converge vers le postulat selon lequel la dimension relationnelle apportée par l'environnement est fondamentale dans le développement des vulnérabilités physiologiques et psychiques du sujet. Dans ce sens, les relations d'attachement ont été particulièrement étudiées. A l'âge adulte, par exemple, la qualité des représentations d'attachement semble influencer directement l'expression de gènes impliqués dans les réponses hormonales de stress (Biagini, Pich, Carani, Marrama, & Agnati, 1998; Caldji, Diorio, & Meaney, 2000; Dallman, 2000; De Kloet, Rosenfeld, Van Eekelen, Sutanto, & Levine, 1988; Rincon-Cortes & Sullivan, 2014; Romeo, Tang, & Sullivan, 2009; van Oers, de Kloet, Whelan, & Levine, 1998), illustrant ainsi une perspective épigénétique. Traumatismes précoces et réponses de stress, leur association avec la santé mentale, l'attachement et l'ocytocine Deux objectifs principaux définissent ce travail de doctorat. Le premier est de comprendre comment un événement à portée traumatique, qui a eu lieu pendant la période périnatale, l'enfance ou l'adolescence, peut s'inscrire au niveau physiologique (axe hypotalamico- hypophysaire-surrénalien - axe HPA), au niveau psychopathologique ou encore au niveau de la régulation émotionnelle au cours de l'âge adulte. A ce propos, nous avons évalué les réponses physiologiques (telles que le Cortisol, l'ACTH et l'ocytocine), la présence de psychopathologies (relatives à l'axe I du DSM-IV) et les réponses émotionnelles (telles que la perception au stress) au cours d'une situation de stress de nature psychosociale, induite en laboratoire. Le deuxième objectif de ce travail est de savoir si les représentations d'attachement peuvent médiatiser ces effets, chez des individus exposés à différents événements à portée traumatique. Dans ce but, trois populations ont été considérées. La première est relative à des jeunes adultes nés grands prématurés ; la deuxième, concerne des femmes adultes ayant vécu un ou plusieurs abus sexuels au cours de leur enfance ou de leur adolescence et enfin la troisième est constituée de personnes adultes qui ont survécu à une maladie grave (cancer) pendant leur enfance ou leur adolescence. Enfin, ces trois populations sont comparées à des groupes contrôle. La prise en considération de différents types de traumatismes a permis de relever : premièrement, qu'un événement à portée traumatique de nature différente, peut influencer de manière semblable les structures neuronales, par exemple l'hypocortisolémie ; deuxièmement, qu'un dysfonctionnement de l'axe HPA n'aboutit pas nécessairement à la présence de signes de souffrance mentale ; enfin, des effets protecteurs ont été mis en évidence. Ces facteurs sont sous-tendus, d'un point de vue psychologique, par les représentations d'attachement et, d'un point de vue physiologique, par la sécrétion d'ocytocjne périphérique. Traumatismes précoces et réponses de stress, leur association avec la santé mentale, l'attachement et l'ocytocine -- When an individual is faced by a stressful situation, one of the most notable responses is the activation of the HPA axis, which is characterized by a heightened level of glucocortisoids in the blood. In general, this is an adaptive hormonal response which prepares the individual both physically and cognitively for a specific action (Axelrod & Reisine, 1984; Chrousos & Gold, 1992; N. M. Kaplan, 1988; McEwen, 2004). However, should a person be confronted to stressful situations very early and repeatedly in their development, this physiologic response may be altered and become maladapted (Anand, 1993; Bremner et al., 1995; Meaney et al., 1996; Mirescu et al., 2004; Plotsky & Meaney, 1993; Sapolsky, 2000) which can be associated to emotional (McEwen, 2000) and cognitive disorders(McEwen & Sapolsky, 1995). Throughout adulthood, the result of these psychoneuroendocrine alterations affects the activation of the HPA axis and are noticeable during less intense stressful situations (Graham et al., 1999; Mirescu et al., 2004; Stam et al., 2000; A. Taylor et al., 2000). HPA axis dysregulation appears to represent a factor of vulnerability linked to psychological and physical disorders in adults (Heim, Ehlert, et al., 2000; Heim & Nemeroff, 1999; Heim, Newport, et al., 2008). Nonetheless, these vulnerabilities may be influenced by further protection factors. The literature, based on translational studies (animals and humans), suggests that relationships formed in the context of the individual's environment are fundamental in the development of their physiological and psychological vulnerabilities. Thus, attachment relationships have been particularly studied. In adulthood, for example, the quality of attachment representations appear to influence directly the expression of genes involved in the hormonal responses to stress (Biagini et al., 1998; Caldji et al., 2000; Dallman, 2000; De Kloet et al., 1988; Rincon-Cortes & Sullivan, 2014; Romeo et al., 2009; van Oers et al., 1998). With the goal to study these dimensions, two principal objectives define these doctoral study. The first is to understand how an event considered to be traumatic, which took place during early infancy, infancy, or adolescence, could influence physiology (HPA axis), psychopathology or emotional regulation during adulthood. Therefore we have evaluated the presence of psychopathologies (relative to axis I of the DSM), physiological responses (such as Cortisol, ACTH and oxytocin) and emotional responses (such as perception of stress) throughout a psychosocial stress situation, conducted in a laboratory setting. The second objective of this study is to understand if attachment representations can mediate these effects, in individuals exposed to three different types of traumatic events. Therefore, three populations have been considered. The first is young adults who were born prematurely; the second concerns adult women who have suffered sexual abuse, on one or more occasions, during their childhood or adolescence; finally the third group is constituted of people who have survived a grave childhood illness. These populations were all compared to control groups. The consideration of different types of traumatic events has demonstrated, firstly, that different events which are considered to be traumatic can similarly influence neuronal structures, for example hypocortisolism. Secondly, that an HPA axis disorder does not necessarily lead to the presence of mental signs of distress, as is the case for those born very prematurely. Finally, protective effects were demonstrated, distinctively from a psychological point of view, by attachment representations and furthermore by peripheral oxytocin secretion from a physiological perspective.

Is the relationship between major depressive disorder and self-reported alcohol use disorder an artificial one ?

AIMS: Many studies have suggested a close relationship between alcohol use disorder (AUD) and major depressive disorder (MDD). This study aimed to test whether the relationship between self-reported AUD and MDD was artificially strengthened by the diagnosis of MDD. This association was tested comparing relationships between alcohol use and AUD for depressive people and non-depressive people. METHODS: As part of the Cohort Study on Substance Use Risk Factors, 4352 male Swiss alcohol users in their early twenties answered questions concerning their alcohol use, AUD and MDD at two time points. Generalized linear models for cross-sectional and longitudinal associations were calculated. RESULTS: For cross-sectional associations, depressive participants reported a higher number of AUD symptoms (β = 0.743, P < 0.001) than non-depressive participants. Moreover, there was an interaction (β = -0.204, P = 0.001): the relationship between alcohol use and AUD was weaker for depressive participants rather than non-depressive participants. For longitudinal associations, there were almost no significant relationships between MDD at baseline and AUD at follow-up, but the interaction was still significant (β = -0.249, P < 0.001). CONCLUSION: MDD thus appeared to be a confounding variable in the relationship between alcohol use and AUD, and self-reported measures of AUD seemed to be overestimated by depressive people. This result brings into question the accuracy of self-reported measures of substance use disorders. Furthermore, it adds to the emerging debate about the usefulness of substance use disorder as a concept, when heavy substance use itself appears to be a sensitive and reliable indicator.

Extension des prestations de type "équipe mobile" aux foyers socio-éducatifs: projet pilote dans le canton de Vaud [Extension of mobile team services to socio-educational home: pilot project in the Vaud canton].

L'objectif principal de ce projet d'extension des prestations, de type Antenne d'intervention dans le milieu pour enfants et adolescents (AIMEA) aux foyers socio-éducatifs pour l'ensemble du canton de Vaud, vise à décloisonner les champs socio-éducatifs et pédopsychiatriques. 64 patients ont fait l'objet d'une évaluation au cours de la phase pilote (après une année de fonctionnement). De plus, une enquête de satisfaction a été effectuée soit à la fin du suivi, soit à la fin de la phase pilote de ce projet (au 31.12.2012). Cette expérience très positive, relevée par une grande majorité des acteurs impliqués dans la prise en charge socio-éducative et pédopsychiatrique des mineurs, suscite un désir d'extension des prestations de type équipe mobile à d'autres structures ou à d'autres types de situations. The main objective of this project about mobile team service extension to the socio-educational home of the whole Vaud canton targets to decompartmentalize the socio-educational and youth-psychiatry domains. 64 patient were assessed during this pilot phase (after one-year functioning). In addition, a satisfaction survey was done either at the end of the follow up or at the end of the pilot phase of the project (31.12.2012). This experience was very positive as highlighted by the vast majority of the person involved in the socio-educational and youth-psychiatric domains taking care of youth. A desire of extension of mobile team service to other institutional structure or other situations was expressed.

Patterns of practice of regional nodal irradiation in breast cancer: results of the European Organization for Research and Treatment of Cancer (EORTC) NOdal Radiotherapy (NORA) survey.

BACKGROUND: Predicting outcome of breast cancer (BC) patients based on sentinel lymph node (SLN) status without axillary lymph node dissection (ALND) is an area of uncertainty. It influences the decision-making for regional nodal irradiation (RNI). The aim of the NORA (NOdal RAdiotherapy) survey was to examine the patterns of RNI. METHODS: A web-questionnaire, including several clinical scenarios, was distributed to 88 EORTC-affiliated centers. Responses were received between July 2013 and January 2014. RESULTS: A total of 84 responses were analyzed. While three-dimensional (3D) radiotherapy (RT) planning is carried out in 81 (96%) centers, nodal areas are delineated in only 51 (61%) centers. Only 14 (17%) centers routinely link internal mammary chain (IMC) and supraclavicular node (SCN) RT indications. In patients undergoing total mastectomy (TM) with ALND, SCN-RT is recommend by 5 (6%), 53 (63%) and 51 (61%) centers for patients with pN0(i+), pN(mi) and pN1, respectively. Extra-capsular extension (ECE) is the main factor influencing decision-making RNI after breast conserving surgery (BCS) and TM. After primary systemic therapy (PST), 49 (58%) centers take into account nodal fibrotic changes in ypN0 patients for RNI indications. In ypN0 patients with inner/central tumors, 23 (27%) centers indicate SCN-RT and IMC-RT. In ypN1 patients, SCN-RT is delivered by less than half of the centers in patients with ypN(i+) and ypN(mi). Twenty-one (25%) of the centers recommend ALN-RT in patients with ypN(mi) or 1-2N+ after ALND. Seventy-five (90%) centers state that age is not considered a limiting factor for RNI. CONCLUSION: The NORA survey is unique in evaluating the impact of SLNB/ALND status on adjuvant RNI decision-making and volumes after BCS/TM with or without PST. ALN-RT is often indicated in pN1 patients, particularly in the case of ECE. Besides the ongoing NSABP-B51/RTOG and ALLIANCE trials, NORA could help to design future specific RNI trials in the SLNB era without ALND in patients receiving or not PST.

An outbreak of Arthroderma vanbreuseghemii dermatophytosis at a veterinary school associated with an infected horse.

We report a case of an outbreak of inflammatory dermatophytoses caused by Arthroderma vanbreuseghemii (formally Trichophyton mentagrophytes pro parte) that involved an infected horse, the owner and at least 20 students, staff and stablemen at a veterinary school in Bern (Switzerland) that presented highly inflammatory dermatitis of the body and the face. Transmission from human to human was also recorded as one patient was the partner of an infected person. Both the phenotypic characteristics and ITS sequence of the dermatophytes isolated from the horse and patients were identical, consistent with the conclusion that the fungus originated from the horse. Three infected persons had not been in direct contact with the horse. Although direct transmission from human to human cannot be ruled out, fomites were most likely the source of infection for these three patients. Inspection of the literature at the end of the nineteenth and beginning of the twentieth century revealed that this dermatophyte was frequently transmitted from horses to humans in contact with horses (stablemen, coachmen, carters and artillery soldiers). The rarity of the present case report at the present time is likely related to the transformation of civilisation from the nineteenth century to nowadays in Europe with the change of horse husbandry. In addition, the inadequate immune response of the horse and the high number of people in contact with it at the equine clinic may explain the exceptional aspect of this case report.