European guidelines for sclerotherapy in chronic venous disorders.

AIM: Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy. METHODS: This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7-10 May 2012 in Mainz. The conference was organized by the German Society of Phlebology. These guidelines review the present state of knowledge as reflected in published medical literature. The regulatory situation of sclerosant drugs differs from country to country but this has not been considered in this document. The recommendations of this guideline are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines. RESULTS: This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, polidocanol and sodium tetradecyl sulphate. Other sclerosants are not discussed in detail. The guideline gives recommendations concerning indications, contraindications, side-effects, concentrations, volumes, technique and efficacy of liquid and foam sclerotherapy of varicose veins and venous malformations.

The impact of personality characteristics on the clinical expression in neurodegenerative disorders--a review.

Clinical experience suggests that longstanding personality characteristics as a person's most distinctive features of all are likely to play a role in how someone with dementia copes with his increasing deficiencies. Personality characteristics may have a pathoplastic effect on both behavioral and psychological symptoms (BPS) or on cognition as well as cognitive decline. Cognitive disorders accompanied by BPS are a tremendous burden for both the patient and their proxies. This review suggests that premorbid personality characteristics are co-determinants of BPS in cognitive disorders, but much effort is needed to clarify whether or not specific premorbid personality traits are associated with specific BPS as no strong links have so far emerged. This review further shows that a growing field of research is interested in the links not only between quite short-lived emotional states and cognitive processes, but also between longstanding personality traits and cognition in both healthy individuals and patients with neurodegenerative disorders. Furthermore, a few studies found that specific premorbid personality traits may be risk factors for neurodegenerative diseases. However, research findings in this area remain scarce despite a huge literature on personality and cognitive disorders in general. An important shortcoming that hampers so far the progress of our understanding in these domains is the confusion in the literature between longstanding premorbid personality traits and transient personality changes observed in neurodegenerative diseases. Few studies have based their assessments on accepted personality theories and carefully investigated premorbid personality traits in patients with cognitive disorders, although assessing personality may be complicated in these patients. Studying the impact of personality characteristics in cognitive disorders is an especially promising field of research in particular when concomitantly using neurobiological approaches, in particular structural brain imaging and genetic studies as suggested by as yet rare studies. Improved understanding of premorbid personality characteristics as determinants of both BPS or cognitive capacities or decline is likely to influence our attitudes towards the treatment of demented patients and ultimately to help in alleviating a patient's and their proxies' burden.

L'entretien motivationnel, une nouvelle "panacée" dans la prise en charge de patients toxicodépendants ? Une revue de littérature [Motivational interviewing, the new "panacea" for treatment of substance use disorders ? A review of literature]

Cet article aborde l'entretien motivationnel (EM), considéré comme un style thérapeutique centré sur le client et directif, visant à développer la motivation au changement par l'exploration et la résolution de l'ambivalence (Miller, W.R., Rollnick, S., 2002. Motivational interviewing: preparing people for change. The Guilford Press, New York, p. 25). Après une brève présentation théorique de ce style thérapeutique, nous présentons un survol des principaux résultats empiriques relatifs à la question de son efficacité dans la prise en charge des troubles liés à l'utilisation de substances psychoactives. Malgré un corpus important de travaux qui mettent en évidence les effets de l'EM, la question des « ingrédients actifs » reste encore relativement peu explorée. Quelques hypothèses permettant de mieux comprendre le succès de l'EM sont évoquées.

Obstructive Sleep Apnea Severity and Overnight Body Fluid Shift before and after Hemodialysis.

BACKGROUND AND OBJECTIVES: Obstructive sleep apnea is associated with significantly increased cardiovascular morbidity and mortality. Fluid overload may promote obstructive sleep apnea in patients with ESRD through an overnight fluid shift from the legs to the neck soft tissues. Body fluid shift and severity of obstructive sleep apnea before and after hemodialysis were compared in patients with ESRD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Seventeen patients with hemodialysis and moderate to severe obstructive sleep apnea were included. Polysomnographies were performed the night before and after hemodialysis to assess obstructive sleep apnea, and bioimpedance was used to measure fluid overload and leg fluid volume. RESULTS: The mean overnight rostral fluid shift was 1.27±0.41 L prehemodialysis; it correlated positively with fluid overload volume (r=0.39; P=0.02) and was significantly lower posthemodialysis (0.78±0.38 L; P<0.001). There was no significant difference in the mean obstructive apnea-hypopnea index before and after hemodialysis (46.8±22.0 versus 42.1±18.6 per hour; P=0.21), but obstructive apnea-hypopnea index was significantly lower posthemodialysis (-10.1±10.8 per hour) in the group of 12 patients, with a concomitant reduction of fluid overload compared with participants without change in fluid overload (obstructive apnea-hypopnea index +8.2±16.1 per hour; P<0.01). A lower fluid overload after hemodialysis was significantly correlated (r=0.49; P=0.04) with a lower obstructive apnea-hypopnea index. Fluid overload-assessed by bioimpedance-was the best predictor of the change in obstructive apnea-hypopnea index observed after hemodialysis (standardized r=-0.68; P=0.01) in multivariate regression analysis. CONCLUSIONS: Fluid overload influences overnight rostral fluid shift and obstructive sleep apnea severity in patients with ESRD undergoing intermittent hemodialysis. Although no benefit of hemodialysis on obstructive sleep apnea severity was observed in the whole group, the change in obstructive apnea-hypopnea index was significantly correlated with the change in fluid overload after hemodialysis. Moreover, the subgroup with lower fluid overload posthemodialysis showed a significantly lower obstructive sleep apnea severity, which provides a strong incentive to further study whether optimizing fluid status in patients with obstructive sleep apnea and ESRD will improve the obstructive apnea-hypopnea index.

Psychotherapy for Personality Disorders in a Natural Setting: A Pilot Study over Two Years of Treatment.

Long-term assessment of the effects of psychotherapy for personality disorders (PDs) in a natural environment is an important task. Such research contributes to enlarge the practice-based evidence, embedded in broad collaborations between clinicians and researchers in psychotherapy for PDs. The present pilot study used rigorous assessment procedures and incorporated feedback loops of outcome information to the therapists in demonstrating the effects of psychotherapy for PD in a natural setting. The number of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria for any PD was the primary outcome (along with psychological distress, depression, impulsiveness, and quality of life as secondary measures), assessed at intake, 6, 12, 18, and 24 months of psychotherapy for N = 13 patients with PD. Data were analyzed using hierarchical linear modeling. Results demonstrated a large pre-post effect (d = 2.22) for the observer-rated measure (primary outcome), and small to medium effects for the secondary outcomes; these results were corroborated by a steady decrease of symptoms over all five time points, which was significant for several outcomes. These results add a piece to the literature by demonstrating the effects of long-term psychotherapy for PDs in increasingly diverse contexts and suggest that practice-oriented research can be carried out in a collaborative and systematic manner.

Prevalence and Diagnostic Approach to Sleep Apnea in Hemodialysis Patients: A Population Study.

BACKGROUND: Previous observations found a high prevalence of obstructive sleep apnea (OSA) in the hemodialysis population, but the best diagnostic approach remains undefined. We assessed OSA prevalence and performance of available screening tools to propose a specific diagnostic algorithm. METHODS: 104 patients from 6 Swiss hemodialysis centers underwent polygraphy and completed 3 OSA screening scores: STOP-BANG, Berlin's Questionnaire, and Adjusted Neck Circumference. The OSA predictors were identified on a derivation population and used to develop the diagnostic algorithm, which was validated on an independent population. RESULTS: We found 56% OSA prevalence (AHI ≥ 15/h), which was largely underdiagnosed. Screening scores showed poor performance for OSA screening (ROC areas 0.538 [SE 0.093] to 0.655 [SE 0.083]). Age, neck circumference, and time on renal replacement therapy were the best predictors of OSA and were used to develop a screening algorithm, with higher discriminatory performance than classical screening tools (ROC area 0.831 [0.066]). CONCLUSIONS: Our study confirms the high OSA prevalence and highlights the low diagnosis rate of this treatable cardiovascular risk factor in the hemodialysis population. Considering the poor performance of OSA screening tools, we propose and validate a specific algorithm to identify hemodialysis patients at risk for OSA for whom further sleep investigations should be considered.

Sleep in vitro : Erk pathway regulates sleep duration and sleep related genes

To date, for most biological and physiological phenomena, the scientific community has reach a consensus on their related function, except for sleep, which has an undetermined, albeit mystery, function. To further our understanding of sleep function(s), we first focused on the level of complexity at which sleep-like phenomenon can be observed. This lead to the development of an in vitro model. The second approach was to understand the molecular and cellular pathways regulating sleep and wakefulness, using both our in vitro and in vivo models. The third approach (ongoing) is to look across evolution when sleep or wakefulness appears. (1) To address the question as to whether sleep is a cellular property and how this is linked to the entire brain functioning, we developed a model of sleep in vitro by using dissociated primary cortical cultures. We aimed at simulating the major characteristics of sleep and wakefulness in vitro. We have shown that mature cortical cultures display a spontaneous electrical activity similar to sleep. When these cultures are stimulated by waking neurotransmitters, they show a tonic firing activity, similar to wakefulness, but return spontaneously to the "sleep-like" state 24h after stimulation. We have also shown that transcriptional, electrophysiological, and metabolic correlates of sleep and wakefulness can be reliably detected in dissociated cortical cultures. (2) To further understand at which molecular and cellular levels changes between sleep and wakefulness occur, we have used a pharmacological and systematic gene transcription approach in vitro and discovered a major role played by the Erk pathway. Indeed, pharmacological inhibition of this pathway in living animals decreased sleep by 2 hours per day and consolidated both sleep and wakefulness by reducing their fragmentation. (3) Finally, we tried to evaluate the presence of sleep in one of the most primitive species with a neural network. We set up Hydra as a model organism. We hypothesized that sleep as a cellular (neuronal) property may occur with the appearance of the most primitive nervous system. We were able to show that Hydra have periodic rest phases amounting to up to 5 hours per day. In conclusion, our work established an in vitro model to study sleep, discovered one of the major signaling pathways regulating vigilance states, and strongly suggests that sleep is a cellular property highly conserved at the molecular level during evolution. -- Jusqu'à ce jour, la communauté scientifique s'est mise d'accord sur la fonction d'une majorité des processus physiologiques, excepté pour le sommeil. En effet, la fonction du sommeil reste un mystère, et aucun consensus n'est atteint le concernant. Pour mieux comprendre la ou les fonctions du sommeil, (1) nous nous sommes d'abord concentré sur le niveau de complexité auquel un état ressemblant au sommeil peut être observé. Nous avons ainsi développé un modèle du sommeil in vitro, (2) nous avons disséqué les mécanismes moléculaires et cellulaires qui pourraient réguler le sommeil, (3) nous avons cherché à savoir si un état de sommeil peut être trouvé dans l'hydre, l'animal le plus primitif avec un système nerveux. (1) Pour répondre à la question de savoir à quel niveau de complexité apparaît un état de sommeil ou d'éveil, nous avons développé un modèle du sommeil, en utilisant des cellules dissociées de cortex. Nous avons essayé de reproduire les corrélats du sommeil et de l'éveil in vitro. Pour ce faire, nous avons développé des cultures qui montrent les signes électrophysiologiques du sommeil, puis quand stimulées chimiquement passent à un état proche de l'éveil et retournent dans un état de sommeil 24 heures après la stimulation. Notre modèle n'est pas parfait, mais nous avons montré que nous pouvions obtenir les corrélats électrophysiologiques, transcriptionnels et métaboliques du sommeil dans des cellules corticales dissociées. (2) Pour mieux comprendre ce qui se passe au niveau moléculaire et cellulaire durant les différents états de vigilance, nous avons utilisé ce modèle in vitro pour disséquer les différentes voies de signalisation moléculaire. Nous avons donc bloqué pharmacologiquement les voies majeures. Nous avons mis en évidence la voie Erkl/2 qui joue un rôle majeur dans la régulation du sommeil et dans la transcription des gènes qui corrèlent avec le cycle veille-sommeil. En effet, l'inhibition pharmacologique de cette voie chez la souris diminue de 2 heures la quantité du sommeil journalier et consolide l'éveil et le sommeil en diminuant leur fragmentation. (3) Finalement, nous avons cherché la présence du sommeil chez l'Hydre. Pour cela, nous avons étudié le comportement de l'Hydre pendant 24-48h et montrons que des périodes d'inactivité, semblable au sommeil, sont présentes dans cette espèce primitive. L'ensemble de ces travaux indique que le sommeil est une propriété cellulaire, présent chez tout animal avec un système nerveux et régulé par une voie de signalisation phylogénétiquement conservée.

Early detection and intervention for infants at risk of autism spectrum disorders

Autism is a developmental disorder that is characterized by abnonnal social interactions and communications as well as repetitive and restricted activities and interests. There is evidence of a genetic component, as 5% of younger siblings are diagnosed if their older sibling has been diagnosed. Autism is generally not diagnosed until age 3 at the earliest, yet it has been shown that early intervention for children with autism can greatly increase their functioning. Because of this, it is important that symptoms of autism are identified as early as possible so that diagnosis can occur as soon as possible to allow these children the earliest intervention. This thesis was divided into two parts. The first looked at the psychometrics of two proposed measures, the Parent Observation Checklist (POC), administered monthly, and the Infant Behavior Summary Evaluation (mSE), administered bimonthly, to see if they can be used with the infant population to identify autistic symptoms in infants who are at high risk for autism or related problems because they have an older sibling with autism. Study 1 reported acceptable psychometric properties of both the POC and IBSE in terms of test-retest reliability, internal consistency, construct validity and predictive validity. These results provide preliminary evidence that parent report measures can help to detect early symptoms of ASD in infants. The POC was shown to differentiate infants who were diagnosed from a matched group that was not diagnosed by 3 years of age. The second part of this thesis involved a telephone interview of parents who reported developmental and/or behavior problems in their high-risk infants that may be early signs of Autism Spectrum Disorder (ASD). During the interview, a service questionnaire was administered to see what interventions (including strategies recommended by the researchers) their at risk infants and affected older siblings were receiving, how satisfied the parents were with them and how effective they felt the interventions were. 3 Study 2 also yielded promising results. Parents utilized a variety of services for at risk infants and children with ASD. The interventions included empirically validated early intervention (e.g., ABA) to non-empirically validated treatments (e.g., diet therapy). The large number of nonempirically validated treatments parents used was surprising, yet parents reported being involved and satisfied, and thought that the services were effective. Parents' perceptions of their stress levels went down slightly and feelings of competence rose when they accessed services for their infants. Overall, the results of this thesis provide new evidence that parent-report methods hold promise as early detection instruments for ASD in at-risk infants. More research is needed to further validate these instruments as well as to understand the variables related to the parents' choice of early intervention for their at risk and affected children.

Electrophysiological analysis of the sleep onset period : a comparison between subjects with long term insomnia complaints associated with mild traumatic brain injury and matched controls /

The purpose of the current undertaking was to study the electrophysiological properties of the sleep onset period (SOP) in order to gain understanding into the persistent sleep difficulties of those who complain of insomnia following mild traumatic brain injury (MTBI). While many believe that symptoms of post concussion syndrome (PCS) following MTBI resolve within 6 to 12 months, there are a number of people who complain of persistent sleep difficulty. Two models were proposed which hypothesize alternate electrophysiological presentations of the insomnia complaints of those sustaining a MTBI: 1) Analyses of standard polysomnography (PSG) sleep parameters were conducted in order to determine if the sleep difficulties of the MTBI population were similar to that of idiopathic insomniacs (i.e. greater proportion ofREM sleep, reduced delta sleep); 2) Power spectral analysis was conducted over the SOP to determine if the sleep onset signature of those with MTBI would be similar to psychophysiological insomniacs (characterized by increased cortical arousal). Finally, exploratory analyses examined whether the sleep difficulties associated with MTBI could be explained by increases in variability of the power spectral data. Data were collected from 9 individuals who had sustained a MTBI 6 months to 5 years earlier and reported sleep difficulties that had arisen within the month subsequent to injury and persisted to the present. The control group consisted of 9 individuals who had experienced neither sleep difficulties, nor MTBI. Previous to spending 3 consecutive uninterrupted nights in the sleep lab, subjects completed questionnaires regarding sleep difficulties, adaptive functioning, and personality.

A dose-response investigation of the attentional blink during sleep restriction /

Recent dose-response sleep restriction studies, in which nightly sleep is curtailed to varying degrees (e.g., 3-, 5-, 7-hours), have found cumulative, dose-dependent changes in sleepiness, mood, and reaction time. However, brain activity has typically not been measured, and attentionbased tests employed tend to be simple (e.g., reaction time). One task addressing the behavioural and electrophysiological aspects of a specific attention mechanism is the Attentional Blink (AB), which shows that the report accuracy of a second target (T2) is impaired when it is presented soon after a first target (Tl). The aim of the present study was to examine behavioural and electrophysioiogical responses to the AB task to elucidate how sleep restriction impacts attentional capacity. Thirty-six young-adults spent four consecutive days and nights in a sleep laboratory where sleep, food, and activity were controlled. Nightly sleep began with a baseline sleep (8 hours), followed by two nights of sleep restriction (3,5 or 8 hours of sleep), and a recovery sleep (8 hours). An AB task was administered each day at 11 am. Results from a basic battery oftests (e.g., sleepiness, mood, reaction time) confirmed the effectiveness of the sleep restriction manipulation. In terms of the AB, baseline performance was typical (Le., T2 accuracy impaired when presented soon after Tl); however, no changes in any AB behavioural measures were observed following sleep restriction for the 3- or 5-hour groups. The only statistically significant electrophysiological result was a decrease in P300 amplitude (for Tl) from baseline to the second sleep restriction night for the 3-hour group. Therefore, following a brief, two night sleep restriction paradigm, brain functioning was impaired for the TI of the AB in the absence of behavioural deficit. Study limitations and future directions are discussed.

An electrophysiological examination of intentional and inadvertent sleep onset : the effect of intention on the sleep onset process

The main purpose ofthis study was to examine the effect ofintention on the sleep onset process from an electrophysiological point ofview. To test this, two nap conditions, the Multiple Sleep Latency Test (MSLT) and the Repeated Test of Sustained Wakefulness (RTSW) were used to compare intentional and inadvertent sleep onset. Sixteen female participants (aged 19-25) spent two non-consecutive nights in the sleep lab; however, due to physical and technical difficulties only 8 participants produced compete sets of data for analysis. Each night participants were given six nap opportunities. For three ofthese naps they were instructed to fall asleep (MSLT), for the remaining three naps they were to attempt to remain awake (RTSW). These two types of nap opportunities represented the conditions ofintentional (MSLT) and inadvertent (RTSW) sleep onset. Several other sleepiness, performance, arousal and questionnaire measures were obtained to evaluate and/or control for demand characteristics, subjective effort and mental activity during the nap tests. The nap opportunities were scored using a new 9 stage scoring system developed by Hori et al. (1994). Power spectral analyses (FFT) were also performed on the sleep onset data provided by the two nap conditions. Longer sleep onset latencies (approximately 1.25 minutes) were obseIVed in the RTSW than the MSLT. A higher incidence of structured mental activity was reported in the RTSW and may have been reflected in higher Beta power during the RTSW. The decent into sleep was more ragged in the RTSW as evidenced by an increased number shifts towards higher arousal as measured using the Hori 9 stage sleep scoring method. 1ll The sleep onset process also appears to be altered by the intention to remain awake, at least until the point ofinitial Stage 2 sleep (i.e. the first appearance of spindle activity). When only examining the final 4.3 minutes ofthe sleep onset process (ending with spindle activity), there were significant interactions between the type ofnap and the time until sleep onset for Theta, Alpha and Beta power. That is to say, the pattern of spectral power measurements in these bands differed across time as a function ofthe type ofnap. The effect ofintention however, was quite small (,,2 < .04) when compared to the variance which could be accounted for by the passage oftime (,,2 == .10 to .59). These data indicate that intention alone cannot greatly extend voluntary wakefulness if a person is sleepy. This has serious implications for people who may be required to perform dangerous tasks while sleepy, particularly for people who are in a situation that does not allow them the opportunity to engage in behavioural strategies in order to maintain their arousal.

A journey into narrative inquiry : one teacher's lived experience with eating disorders /

In "A Journey Into Narrative Inquiry: One Teacher's Lived Experience With Eating Disorders," an elementary teacher searches for answers regarding how education can help prevent eating disorders by journeying into her own experience of having had such a disorder. This qualitative study is a personal narrative based on an individual's experience, a method appropriate to the sharing of personal voices and stories told in education research. It is an attempt to address the gap found in the research on this topic by offering a subjective and unique perspective of what it is like to live within the nightmare of an eating disorder and by sharing the wisdom gained from having survived such an experience. This narrative inquiry explains how a teacher found herself at a stage where she was willing and ready to share her experience for the sake of research. The story of having had an eating disorder, consisting of both anorexia and bulimia, for over a decade is shared in a genuine, reflective manner. The researcher then shares the analysis of her own story, unpacking the themes of journeying toward voice, self-esteem, self-acceptance, and self and the completion of an M.Ed. degree. Bridges are made which connect these themes to the personal and professional life of the researcher, to the schools in terms of both curriculum and climate, to research directions, and to the larger culture. Suggestions are made for possible changes in educational settings that may help teachers in providing students with some tools and strategies to prevent turning to eating disorders as coping mechanisms. A literature review of eating disorders is included as well, as a guide for others to use when undertaking such qualitative studies.