PFO closure vs. medical therapy in cryptogenic stroke or transient ischemic attack: A systematic review and meta-analysis.

BACKGROUND/OBJECTIVES: This study aims to assess whether patent foramen ovale (PFO) closure is superior to medical therapy in preventing recurrence of cryptogenic ischemic stroke or transient ischemic attack (TIA). METHODS: We searched PubMed for randomized trials which compared PFO closure with medical therapy in cryptogenic stroke/TIA using the items: "stroke or cerebrovascular accident or TIA" and "patent foramen ovale or paradoxical embolism" and "trial or study". RESULTS: Among 650 potentially eligible articles, 3 were included including 2303 patients. There was no statistically significant difference between PFO-closure and medical therapy in ischemic stroke recurrence (1.91% vs. 2.94% respectively, OR: 0.64, 95%CI: 0.37-1.10), TIA (2.08% vs. 2.42% respectively, OR: 0.87, 95%CI: 0.50-1.51) and death (0.60% vs. 0.86% respectively, OR: 0.71, 95%CI: 0.28-1.82). In subgroup analysis, there was significant reduction of ischemic strokes in the AMPLATZER PFO Occluder arm vs. medical therapy (1.4% vs. 3.04% respectively, OR: 0.46, 95%CI: 0.21-0.98, relative-risk-reduction: 53.2%, absolute-risk-reduction: 1.6%, number-needed-to-treat: 61.8) but not in the STARFlex device (2.7% vs. 2.8% with medical therapy, OR: 0.93, 95%CI: 0.45-2.11). Compared to medical therapy, the number of patients with new-onset atrial fibrillation (AF) was similar in the AMPLATZER PFO Occluder arm (0.72% vs. 1.28% respectively, OR: 1.81, 95%CI: 0.60-5.42) but higher in the STARFlex device (0.64% vs. 5.14% respectively, OR: 8.30, 95%CI: 2.47-27.84). CONCLUSIONS: This meta-analysis does not support PFO closure for secondary prevention with unselected devices in cryptogenic stroke/TIA. In subgroup analysis, selected closure devices may be superior to medical therapy without increasing the risk of new-onset AF, however. This observation should be confirmed in further trials using inclusion criteria for patients with high likelihood of PFO-related stroke recurrence.

Le suicide comme langage de l'oppression. Ethnographie d'un service d'urgences psychiatriques

Ce travail s'intéresse à la problématique du suicide à partir de l'émergence en Suisse, vers la fin des années '90, de la prévention du suicide comme préoccupation sociale et politique. Au début, ce sont les milieux associatifs qui ont soulevé à cette question en percevant le suicide comme le reflet d'une souffrance d'origine sociale. Par la suite, la prévention du suicide est progressivement devenue une problématique de santé publique appréhendée essentiellement sous le registre médical comme étant le symptôme d'une pathologie psychiatrique. Après une première partie consacrée aux processus sociopolitiques et aux transformations morales touchant le suicide et sa prévention, ce travail approfondit, au travers d'un terrain ethnographique, la prise en charge des personnes présentant des problématiques suicidaires au sein d'un service d'urgences psychiatriques.Malgré une approche se voulant biopsychosociale, l'analyse des discours et des pratiques soignantes montre que la dimension sociale est largement négligée, conduisant à une médicalisation de situations de détresse qui sont principalement de nature sociale. En effet, parmi la population qui fréquente le service, on observe une surreprésentation de personnes issues des classes sociales défavorisées présentant souvent des trajectoires biographiques particulièrement difficiles. Au fil des entretiens avec les patients émerge une analyse voyant la souffrance psychique et la prise en charge psychiatrique comme étant aujourd'hui une manière d'obtenir une reconnaissance sociale et symbolique. Les problématiques suicidaires peuvent ainsi être interprétées comme une forme d'expression, un langage au travers duquel s'exprime la position sociale défavorisée.En adoptant une posture militante construite à partir de la réalité ethnographique, les problématiques suicidaires sont analysées comme l'expression d'une condition d'oppression liée à un cadre social et économique de plus en plus contraignant, à des rapports de pouvoir inégaux ainsi qu'à une lecture individualisante, médicalisante et pathologisante des problèmes sociaux.The present thesis discusses suicide prevention in Switzerland, which emerged as a social and political issue at the end of the '90s. At first, this question was taken up by associations considering suicide as a reflection of social suffering. Thereafter, suicide prevention gradually became a public health matter conceived with a medical approach as a symptom of a psychiatric disease. The first part of this work analyzes the sociopolitical process and moral transformations concerning suicide and its prevention. The second part is based on an ethnographic fieldwork conducted in a psychiatric emergency unit that attends people who have tried to attempt their life or consider doing it. Through the analysis of discourses and practices of the medical staff, this research shows that the social aspect of suicide is widely neglected, leading to a medicalization of social problems. In fact, amongst patients attending the emergency unit, there is an over-­-representation of people from disadvantaged classes having very difficult life stories. Interviews with patients also revealed that psychic suffering and psychiatric treatment is nowadays a way to get social and symbolical recognition. Suicidal problems can be understood as a language expressing a disadvantaged social position. By adopting a militant position constructed from the ethnographic reality, suicide is analyzed as the expression of an oppressed condition related to a more and more restricted social and economic situation, to unequal power relations as well as to an individualistic, medical and pathological interpretation of social problems.

La prévention du suicide en milieu scolaire est-elle possible [Is it possible to run suicide prevention interventions within the school setting?]

Suicide represent the second cause of death in Switzerland and, between 15 and 20 years of age, 8% of girls and 4% of boys have attempted suicide at least once in their life. "Universal" primary prevention in schools is usually run through courses dealing with the issue of suicide and which are systematically provided to all pupils. There is no evidence that they have any positive effect and even they may be in some instances harmful. The training of professionals working in the school setting to better identify and refer adolescents facing risky situation is probably effective. Another promising approach is the one which aims at improving the school climate in increasing social connectedness and the pupils' life skills. Finally, the school which faces a suicide should set up debriefing activities, thus deterring vulnerable pupils to engage in violent acting as a result of a contamination process.

An epidemiological and clinical approach to adolescent suicide. A comparison between suicidal and non-suicidal clinical groups in a health foundation center for French students.

Suicidal behaviour among young people represents a major public health problem. This study seeks to compare the major sociological, clinical, schooling and family features of suicidal and non-suicidal subgroups of adolescents hospitalised in the Health Foundation Center for French Students of neufmoutiers en Brie (France). All these adolescents suffered from the severe mental disorders. The adolescents from the suicidal subgroup presented significantly fewer psychoses and more mood disorders than those of the non-suicidal subgroup. Half of the patients from the suicidal subgroup presented some features of personality disorders, mostly borderline personality disorders. Nevertheless, their global functioning was more frequently improved between admission and discharge than was the case for the non-suicidal group.

Adolescent's suicide attempts: populations at risk, vulnerability, and substance use.

Adolescence corresponds to a transition period that requires adaptation and change capacities and skills. Most young people succeed with this challenge, whereas a minority fail. In order to identify with the teenage culture, become autonomous, and differentiate from their parents, some adolescents choose to use drugs, beginning with the use of cigarettes, alcohol, cannabis, followed by other illicit drugs such as opiates and stimulants. A high proportion of these adolescents attempt suicide, which is the primary cause of death during adolescence in many European countries. Who are the "vulnerable" adolescents? What are the mechanisms that can explain the varieties of drug-use initiation or suicide attempts? Can "protective factors" be identified? What kind of strategies might be developed at a social and political level in order to prevent or to minimize drug abuse and suicide attempts, among other harmful behaviors? These issues will be discussed on the basis of the recent literature and in the light of a recent study carried out in the French-speaking part of Switzerland on large cohorts of adolescent drug users. Unresolved critical issues are noted and future needed research is suggested.

Nonvitamin-k-antagonist oral anticoagulants in patients with atrial fibrillation and previous stroke or transient ischemic attack: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND PURPOSE: To assess whether the combined analysis of all phase III trials of nonvitamin-K-antagonist (non-VKA) oral anticoagulants in patients with atrial fibrillation and previous stroke or transient ischemic attack shows a significant difference in efficacy or safety compared with warfarin. METHODS: We searched PubMed until May 31, 2012, for randomized clinical trials using the following search items: atrial fibrillation, anticoagulation, warfarin, and previous stroke or transient ischemic attack. Studies had to be phase III trials in atrial fibrillation patients comparing warfarin with a non-VKA currently on the market or with the intention to be brought to the market in North America or Europe. Analysis was performed on intention-to-treat basis. A fixed-effects model was used as more appropriate than a random-effects model when combining a small number of studies. RESULTS: Among 47 potentially eligible articles, 3 were included in the meta-analysis. In 14 527 patients, non-VKAs were associated with a significant reduction of stroke/systemic embolism (odds ratios, 0.85 [95% CI, 074-0.99]; relative risk reduction, 14%; absolute risk reduction, 0.7%; number needed to treat, 134 over 1.8-2.0 years) compared with warfarin. Non-VKAs were also associated with a significant reduction of major bleeding compared with warfarin (odds ratios, 0.86 [95% CI, 075-0.99]; relative risk reduction, 13%; absolute risk reduction, 0.8%; number needed to treat, 125), mainly driven by the significant reduction of hemorrhagic stroke (odds ratios, 0.44 [95% CI, 032-0.62]; relative risk reduction, 57.9%; absolute risk reduction, 0.7%; number needed to treat, 139). CONCLUSIONS: In the context of the significant limitations of combining the results of disparate trials of different agents, non-VKAs seem to be associated with a significant reduction in rates of stroke or systemic embolism, hemorrhagic stroke, and major bleeding when compared with warfarin in patients with previous stroke or transient ischemic attack.

Substance use and suicidal conduct: a study of adolescents hospitalized for suicide attempt and ideation.

AIM: To study the prevalence of psychoactive substance use disorder (PSUD) among suicidal adolescents, psychoactive substance intoxication at the moment of the attempt, and the association between PSUD at baseline and either occurrence of suicide or repetition of suicide attempt(s). METHODS: 186 adolescents aged 16 to 21 y hospitalized for suicide attempt or overwhelming suicidal ideation were included (T0); 148 of them were traced again for evaluations after 6 mo (T1) and/or 18 mo (T2). DSM-IV diagnoses were assessed each time using the Mini International Neuropsychiatric Interview. RESULTS: At T0, 39.2% of the subjects were found to have a PSUD. Among them, a significantly higher proportion was intoxicated at the time of the attempt than those without PSUD (44.3% vs 25.4%). Among the 148 adolescents who could be traced at either T1 or T2, two died from suicide and 30 repeated suicide attempts once or more times. A marginally significant association was found between death by suicide/repetition of suicide attempt and alcohol abuse/dependence at baseline (OR=3.3, 95% CI 0.7-15.0; OR=2.6, 95% CI 0.7-9.3). More than one suicide attempt before admission to hospital at T0 (OR=3.2, 95% CI 1.1-10.0) and age over 19 y at T0 (OR=3.2, 95% CI 1.1-9.2) were independently associated with the likelihood of death by suicide or repetition of suicide attempt. CONCLUSION: Among adolescents hospitalized for suicide attempt or overwhelming suicidal ideation, the risk of death or repetition of attempt is high and is associated with previous suicide attempts--especially among older adolescents--and also marginally associated with PSUD; these adolescents should be carefully evaluated for such risks and followed up once discharged from the hospital.

Ultrastructure of the membrane attack complex of complement: detection of the tetramolecular C9-polymerizing complex C5b-8.

The ultrastructure of the membrane attack complex (MAC) of complement had been described as representing a hollow cylinder of defined dimensions that is composed of the proteins C5b, C6, C7, C8, and C9. After the characteristic cylindrical structure was identified as polymerized C9 [poly(C9)], the question arose as to the ultrastructural identity and topology of the C9-polymerizing complex C5b-8. An electron microscopic analysis of isolated MAC revealed an asymmetry of individual complexes with respect to their length. Whereas the length of one boundary (+/- SEM) was always 16 +/- 1 nm, the length of the other varied between 16 and 32 nm. In contrast, poly(C9), formed spontaneously from isolated C9, had a uniform tubule length (+/- SEM) of 16 +/- 1 nm. On examination of MAC-phospholipid vesicle complexes, an elongated structure was detected that was closely associated with the poly(C9) tubule and that extended 16-18 nm beyond the torus of the tubule and 28-30 nm above the membrane surface. The width of this structure varied depending on its two-dimensional projection in the electron microscope. By using biotinyl C5b-6 in the formation of the MAC and avidin-coated colloidal gold particles for the ultrastructural analysis, this heretofore unrecognized subunit of the MAC could be identified as the tetramolecular C5b-8 complex. Identification also was achieved by using anti-C5 Fab-coated colloidal gold particles. A similar elongated structure of 25 nm length (above the surface of the membrane) was observed on single C5b-8-vesicle complexes. It is concluded that the C5b-8 complex, which catalyzes poly(C9) formation, constitutes a structure of discrete morphology that remains as such identifiable in the fully assembled MAC, in which it is closely associated with the poly(C9) tubule.

Assistance au suicide : une question légitime ou un prétexte ambigu?

L'assistance au suicide est souvent utilisée comme un cheval de Troie en faveur de la légalisation de l'euthanasie active directe. Ces deux problématiques sont pourtant fondamentalement distinctes et demandent chacune une réponse éthique propre.