Search

Resume But Le but de ce travail etait de rendre compte, apres dix annees de pratique, de notre experience de la genitoplastie feminisante chez l’enfant pre-pubere et l’adolescente presentant une anomalie du developpement genital (ADG) dans le contexte d’un pays en developpement. Materiels et methode Nous avons mene une etude observationnelle, descriptive et retrospective, allant du 1er novembre 2009 au 1er avril 2019, soit une periode de 9 ans. Ont ete inclus tous les enfants pre-puberes (8–12 ans) et les adolescentes elevees filles, porteuses d’une anomalie du developpement genital, desireuses de chirurgie ainsi que leurs familles et ayant ete l’objet d’une genitoplastie feminisante. Les parametres etudies ont ete : âge au moment de la presentation et de la chirurgie, diagnostic precis, gestes complementaires, suites operatoires, resultat cosmetique et recul. Pour chaque patient, la chirurgie n’a ete de mise qu’apres un diagnostic precis au sein d’une equipe multidisciplinaire experimentee. Les resultats cosmetiques prenaient en compte une reduction de la taille du clitoris et une ouverture separee de l’uretre et du vagin au perinee. Resultats Neufs enfants pre-puberes et adolescentes eleves filles d’âge median 8 ans (EI :10,75) ont ete colliges. L’âge median au moment de la chirurgie etait de 11 ans (EI : 9,5). Les diagnostics precis retenus ont ete : 46, XX ovotestis DSD elevee en fille (n = 2) ; 46, XY DSD insensibilite partielle aux androgenes (n = 2), 46, XY DSD deficit en 5 alpha reductase elevee fille (n = 1), 46, XY DSD deficit en 17-ceto-reductase elevee en fille (n = 1), 46, XY DSD dysgenesie gonadique (mutation du gene NR5A1) elevee en fille (n = 2) ; 45,X/46, XY dysgenesie gonadique mixte elevee en fille (n = 1). La gonadectomie a domine les gestes associes, bilaterale dans 7 cas et unilaterale gauche dans 2 cas. Avec un recul median de 26 mois (EI: 18,25), aucune complication hemorragique n’a ete notee, une retention aigue d’urine transitoire a pu etre observee et les resultats cosmetiques juges satisfaisants. Conclusion La genitoplastie feminisante au Cameroun reste un defi majeur pour le chirurgien pediatrique et elle ne doit se concevoir qu’apres un diagnostic precis. Le traditionnel retard porte a la consultation dans ce contexte apparait comme un avantage, puisqu’il permet aux patientes de participer aux decisions therapeutiques qui engagent leur avenir en termes de developpement psychosocial mais aussi de fertilite. Niveau de preuve 3.

Author(s): Acuna, Josie; Pierre, Cubby M.; Sorenson, Jacob; Adhikari, Srikar | Abstract: Introduction: As physician-performed point-of-care ultrasound (POCUS) becomes more prevalent in the evaluation of patients presenting with various complaints in the emergency department (ED), one application that is significantly less used is breast ultrasound. This study evaluates the utility of POCUS for the assessment of patients with breast complaints who present to the ED and the impact of POCUS on medical decision-making and patient management in the ED.Methods: This was a retrospective review of ED patients presenting with breast symptoms who received a POCUS examination. An ED POCUS database was reviewed for breast POCUS examinations. We then reviewed electronic health records for demographic characteristics, history, physical examination findings, ED course, additional imaging studies, and impact of the POCUS study on patient care and disposition.Results: We included a total of 40 subjects (36 females, 4 males) in the final analysis. Most common presenting symptoms were breast pain (57.5%) and a palpable mass (37.5%).n“Cobblestoning,” ie, dense bumpy appearance, was the most common finding on breast POCUS, seen in 50% of the patients. Simple fluid collections were found in 37.5% of patients.Conclusion: Our study findings illustrate the utility of POCUS in the evaluation of a varietyof breast complaints in the ED.

Oscillations in the granule cell layer (GCL) of the cerebellar cortex have been related to behavior and could facilitate communication with the cerebral cortex. These local field potential (LFP) oscillations, strong at 4-12 Hz in the rodent cerebellar cortex during awake immobility, should also be an indicator of an underlying influence on the patterns of the cerebellar cortex neuronal firing during rest. To address this hypothesis, cerebellar cortex LFPs and simultaneous single-neuron activity were collected during LFP oscillatory periods in the GCL of awake resting rats. During these oscillatory episodes, different types of units across the GCL and Purkinje cell layers showed variable phase-relation with the oscillatory cycles. Overall, 74% of the Golgi cell firing and 54% of the Purkinje cell simple spike (SS) firing were phase-locked with the oscillations, displaying a clear phase relationship. Despite this tendency, fewer Golgi cells (50%) and Purkinje cell's SSs (25%) showed an oscillatory firing pattern. Oscillatory phase-locked spikes for the Golgi and Purkinje cells occurred towards the peak of the LFP cycle. GCL LFP oscillations had a strong capacity to predict the timing of Golgi cell spiking activity, indicating a strong influence of this oscillatory phenomenon over the GCL. Phase-locking was not as prominent for the Purkinje cell SS firing, indicating a weaker influence over the Purkinje cell layer, yet a similar phase relation. Overall, synaptic activity underlying GCL LFP oscillations likely exert an influence on neuronal population firing patterns in the cerebellar cortex in the awake resting state and could have a preparatory neural network shaping capacity serving as a neural baseline for upcoming cerebellar operations.

Many studies have highlighted concerns about the completeness and quality of information found online and how this may affect patients' education about their medical problems. One aspect of internet usage that has received less attention in the literature, however, is patient perception of the information that is gathered online, and how patients use it related to their musculoskeletal care.The objective of the study is to utilize a cross-sectional study design to describe internet usage and patient perceptions of orthopedic online information and to identify differences in usage patterns.One thousand two hundred ninety-six questionnaires were distributed to consecutive patients at orthopedic outpatient clinics which consisted of questions pertaining to patients' internet use. Basic demographic data were collected, and subgroup analyses were performed to examine the effect of three variables (age, gender, and clinic type) on various outcomes.84.9% of patients reported access to the internet. Of patients with internet access, 64.7% reported using the internet for obtaining orthopedic information. 43.1% of the respondents who searched for orthopedic information rated it as "very useful," 56.3% found it "somewhat useful," and 0.6% found it "not at all useful". Younger patients were more likely to have used the internet for health and orthopedic information and to have found this information either very or somewhat useful. Males were more likely to have found the internet information very useful. Overall, only 33.7% of patients who researched their current orthopedic complaint accessed the institutional website for information.A large proportion of patients use the internet to research orthopedic information and most patients, especially younger males, find the information useful.

Resume Introduction En France, 26 equipes regionales ressources de soins palliatifs pediatriques (ERRSPP) ont ete creees entre 2008 et 2012. Nous avons conduit la premiere etude prospective francaise visant a decrire les caracteristiques du recours initial a une ERRSPP et analyser les reponses apportees par cette equipe. Materiel et methodes Toutes les demandes d’interventions formulees a l’ERRSPP entre septembre 2013 et septembre 2014 ont ete recueillies de facon prospective a l’aide d’un questionnaire comportant : les elements demographiques et cliniques du patient (âge, sexe, pathologie), les caracteristiques de la demande (origine du demandeur, specialite du service, motif de la demande) et de la reponse apportee par l’ERRSPP (intervalle diagnostic initial–demande, duree de la prise en charge, deces eventuel, modifications de la demande initiale). Les pathologies ont ete classees dans l’un des 6 groupes de maladies de soins palliatifs pediatriques (SPP), selon les normes edictees par l’Association canadienne de soins palliatifs. Resultats Nous avons recense 67 demandes, concernant 61 patients (37 garcons). L’âge median etait de 49,8 mois [2,3–145]. Les motifs de demande ont ete multiples : reunion ethique pluridisciplinaire (42 %), coordination (34 %), aide a la prise en charge symptomatique (21 %), aide au domicile (19 %), soutien psychologique (15 %), enseignement (9 %) et discussion autour d’un cas (6 %). La demande d’une reunion ethique a ete predominante pour la periode neonatale (61 %) alors que la coordination de la prise en charge l’a ete pour les enfants et adolescents (78 % au-dela de 4 ans). Le delai median « diagnostic–demande » rapporte aux groupes de maladies a ete court pour le groupe 5 (neonatalogie : 0,36 mois) et long pour le groupe 4 (maladies irreversibles et non evolutives : 54,6 mois) (p Conclusion Cette etude montre l’heterogeneite du premier recours a une equipe de SPP, validant ainsi les differentes missions devolues aux ERRSPP et la necessite d’une equipe pluridisciplinaire. La reponse de l’ERRSPP a ete elargie dans la moitie des cas, demontrant une modulation des besoins dans le temps.

Introduction Attention deficit hyperactivity disorder (ADHD) is a frequent neurodevelopmental mental disorder. It can persist in adulthood and be expressed as a cognitive complaint. Methods We conducted a descriptive study in a French memory center concerning patients seen over a period of two years. All patients for whom the final diagnosis was ADHD were included. All patients benefited from standard neuropsychological tests and a psychiatric specific consultation. Results Thirteen patients were included with an average age of 50.2 ± 19 years. Main complaints related to memory, attention, focusing and organizational functioning. These difficulties had negative social, professional and academic consequences. ADHD history in descendants was noted in 46% of patients. More than 20% of subjects had motor, verbal or mental restlessness. Neuropsychological assessment highlighted impaired performances in executive functions (38%), sustained attention (67%), divided attention (45%), working memory (46%) and information processing speed (75%). A psychiatric history or comorbidities were present in 85% of patients, mostly of the anxio-depressive type. The more prevalent presentations of ADHD were the combined (38%) and inattentive (38%) types. Discussion Adult ADHD can masquerade as a cognitive impairment, including a stable cognitive complaint from infancy to old age. Inattentive, hyperactive and impulsive symptoms change with time and become more internalized (such as concentration difficulties or mental restlessness). No neuropsychological pattern has been reported but fluctuating deficits in sustained, divided attention, working memory and information processing speed are frequently observed in adult ADHD. A specific psychiatric expertise is essential in diagnosis and care for ADHD and its commonly associated psychiatric comorbidities.

Antipsychotics are some of the most frequently prescribed medications not only for psychotic disorders and symptoms but also for a wide range of on-label and off-label indications. Because second-generation antipsychotics have largely replaced first-generation antipsychotics as first-line options due to their substantially decreased risk of extrapyramidal side effects, attention has shifted to other clinically concerning adverse events associated with antipsychotic therapy. The focus of this article is to update the nonextrapyramidal side effects associated with second-generation antipsychotics. Issues surrounding diagnosis and monitoring as well as clinical management are addressed.

OBJECTIVE To demonstrate the effectiveness of a Diabetes Prevention Program-inspired 12-month behavioral intervention for patients with severe mental illness (SMI) and medication-associated obesity. METHOD This randomized, controlled, parallel, superiority study screened 225 volunteers from November 2005 to August 2008 at the VA Greater Los Angeles Healthcare System. 122 outpatients with DSM-IV-diagnosed SMI taking antipsychotic medications who had ≥ 7% weight gain or body mass index (BMI) > 25 were randomized by computer-generated number to Lifestyle Balance treatment intervention (n = 60) or usual care control (n = 62) groups. Clinical raters were masked to randomization. Treatment intervention included weekly classes and individual counseling for 8 weeks, food and exercise diaries, rewards, caregiver consultations, and monthly booster classes and counseling for 1 year. Controls received self-help materials and visited at equivalent intervals without formal classes or counseling. Outcomes were changes in anthropometric measurements, psychiatric symptoms, health knowledge, and glucose, hemoglobin A1c, and lipid levels. RESULTS Our intention-to-treat analysis found significant differences in predicted trajectory of mean weight change between the groups over 12 months (P < .01), with treatment participants expected to lose an average 4.6 kg, while control participants would gain an average 0.6 kg. BMI and body fat percentage followed the same pattern. Both groups demonstrated statistically significant improvements in health knowledge quiz scores over time (P = .006), without significant difference between groups. CONCLUSIONS Treatment was more effective than usual care control in treating medication-associated obesity, independent of SMI diagnosis, antipsychotic medication, and knowledge gained, suggesting that behavioral interventions are effective in SMI patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00344500.

Objectives: This study sought to determine clinical, procedural, and treatment factors associated with acute stent thrombosis (AST) in the EUROMAX (European Ambulance Acute Coronary Syndrom...

Prescription stimulant medications have been sought for cognitive “neuroenhancement”, the practice of enhancing ostensibly normal cognitive function such as attention span, focus, and memory. This trend, particularly studied in college students, has driven a debate about many ethical aspects related to cognitive enhancement; however, the central role of physicians and the medical ethics of this practice have been minimally investigated. In this paper, a clinical case serves as the focal point to review the current state of prescription stimulant use for enhancement, beginning with the medical and legal problems related to the surreptitious, yet common, behaviors of diversion and malingering. In contrast, there may be a growing trend for individuals to seek prescription stimulants “openly” (without malingering or diversion) as a direct request from their physician, which leads to complex ethical questions. A model of clinical-ethical decision making (the “four-box model” from Jonsen et al.) is applied to analyze the factors that a physician must consider when deciding whether to engage in the open prescribing of a stimulant neuroenhancer to otherwise healthy, autonomous adults. Four domains are explored in depth: medical indications, quality of life/beneficence, patient preferences, and contextual factors. Relevant experiences from the medical disciplines involved in athletic enhancement and cosmetic enhancement are discussed. Although an overall ethical framework for neuroenhancement continues to evolve, from a perspective of medical ethics there are presently significant reasons to be wary of cognitive neuroenhancement with stimulant medications.

SummaryThe language of psychiatry can be ambiguous and idiosyncratic, reflecting the elastic borders of mental illness and psychiatric disorder. This problem is not unique to psychiatry, but as the medical specialty moves closer towards a 'spectrum view’ of mental illness, psychiatric terminology increasingly risks misappropriation and conflation with lay concepts of normal suffering. Deciding what words mean and how psychiatric disorders are defined requires ongoing consideration of the pragmatic consequences, both intended and unintended. Refining the lexicon of psychiatry with an eye towards precision and the minimisation of stigma requires that terms be revised and updated from time to time, but often suitable word replacements remain elusive.

Veterans with mental illness tend to have shorter life spans and suboptimal physical health because of a variety of factors. These factors include poor nutrition, being overweight, and smoking cigarettes. Nonphysical contributors that may affect quality of life are the stigma associated with mental illness, social difficulties, and spiritual crises. Current mental health treatment focuses primarily on the delivery of medication and evidence-based psychotherapies, which may not affect all the above areas of a Veteran's life as they focus primarily on improving psychological symptoms. Clinicians may find greater success using integrative, comprehensive, multifaceted programs to treat these problems spanning the biological, psychological, social, and spiritual domains. These pilot studies test an adjunctive, holistic, behavioral approach to treat mental illness. This pilot work explores the hypotheses that engagement in a greater number of therapeutic lifestyle changes (TLCs) leads to improvement in quality of life, reduction of psychiatric symptoms, and weight loss.Institutional Review Boards for human subjects at the Veterans Affairs (VA) Greater Los Angeles and Long Beach Healthcare Systems approved pilot study activities at their sites. Pilot Study 1 was a prospective survey study of Veterans with mental illness, who gained weight on an atypical antipsychotic medication regimen, participating in a weight management study. At each session of the 1-year study, researchers asked a convenience sample of 55 Veterans in the treatment arm whether they engaged in each of the eight TLCs: exercise, nutrition/diet, stress management and relaxation, time in nature, relationships, service to others, religious or spiritual involvement, and recreation. Pilot Study 2 applied the TLC behavioral intervention and examined 19 Veterans with mental illness, who attended four classes about TLCs, received individual counseling over 9 weeks, and maintained journals to track TLC practice. Besides weekly journals, researchers also collected prospective data on quality of life, psychiatric symptoms, vitals, and anthropometric measurements. In both studies, investigators tested for main effects of the total number of TLCs practiced and study week using mixed-effects linear models with independent intercepts by participant.In Study 1, engagement in more TLC behaviors was significantly associated with higher ratings of quality of life, as well as greater weight loss for each additional type of TLC practiced. In Study 2, TLC practice increased significantly over 9 weeks, and was significantly associated with improvements in quality of life and diastolic blood pressure.Counseling Veterans to practice TLCs provides a holistic adjunct to current treatments for mental illness. TLCs may confer multiple benefits upon Veterans with mental illness, enhancing quality of life and well-being along with weight management efforts. As these were pilot studies, the samples sizes were relatively small and a control group was lacking. Our findings may have broader implications supporting a holistic approach in both primary and mental health care settings. Future research will expand this work to address its weaknesses and examine the cost differential between this holistic approach and traditional mental health treatment.

Deprivation-related pathology can take the form of faltering growth, medical neglect, psychomotor delay, and/or behavioral problems, in various combinations.

Weight gain and other metabolic sequelae of antipsychotic medications can lead to medication non-adherence, reduced quality of life, increased costs, and premature mortality. Of the approaches to address this, behavioral interventions are less invasive, cost less, and can result in sustained long-term benefits. We investigated behavioral weight management interventions for veterans with mental illness across four medical centers within the Veterans Affairs (VA) Healthcare System. We conducted a 12-month, multi-site extension of our previous randomized, controlled study, comparing treatment and control groups. Veterans (and some non-veteran women) diagnosed with mental illness, overweight (defined as having a BMI over 25), and required ongoing antipsychotic therapy. One group received “Lifestyle Balance” (LB; modified from the Diabetes Prevention Program) consisting of classes and individual nutritional counseling with a dietitian. A second group received less intensive “Usual Care” (UC) consisting of weight monitoring and provision of self-help. Participants completed anthropometric and nutrition assessments weekly for 8 weeks, then monthly. Psychiatric, behavioral, and physical assessments were conducted at baseline and months 2, 6, and 12. Metabolic and lipid laboratory tests were performed quarterly. Participants in both groups lost weight. LB participants had a greater decrease in average waist circumference [F(1,1244) = 11.9, p

Background: Second-generation antipsychotic medications have proven effective for individuals with serious mental illness (SMI) but may cause weight gain and other metabolic sequelae. Investigators designed and assessed a 12-month behavioral intervention for overweight/obese patients with SMI called “Lifestyle Balance” (LB), based on the Diabetes Prevention Program (DPP), which was tested at 4 VA sites.

Background: The delivery of mental health care is shifting to one that is patient-centered and recovery-oriented, with the goal of increasing quality of life. These pilot studies test an adjunctive, holistic, behavioral approach to treating serious mental illness (SMI) and medication-associated weight gain; investigators hypothesized that engagement in a greater number of therapeutic lifestyle changes (TLCs) leads to improvement in quality of life, reduction of psychiatric symptoms, and weight loss.

Tattooing the skin as a means of personal expression is a ritualized practice that has been around for centuries across many different cultures. Accordingly, the symbolic meaning of tattoos has evolved over time and is highly individualized, from both the internal perspective of the wearer and the external perspective of an observer. Within modern Western societies through the 1970s, tattoos represented a cultural taboo, typically associated with those outside of the mainstream such as soldiers, incarcerated criminals, gang members, and others belonging to marginalized and counter-cultural groups. This paper aims to review the more recent epidemiology of tattoos in Western culture in order to establish that tattooing has become a mainstream phenomenon. We then review psychological and psychiatric aspects of tattoos, with a goal of revising outmoded stigmas about tattooing and helping clinicians working with tattooed patients to facilitate an exploration of the personal meaning of skin art and self-identity. We suggest that as a kind of augmentation of the physical exam, looking at and talking to patients about their tattoos can provide a valuable window into the psyche, informing clinical practice.

Resume Contexte Le syndrome du « bebe secoue » (SBS) associe classiquement des hemorragies intracrâniennes et retiniennes chez un enfant de moins de 2 ans. Les sequelles neurologiques etant frequentes, l’enfant peut pretendre a une indemnisation de son dommage. Notre etude trouve sa justification dans l’absence de litterature consacree au traitement judiciaire des SBS. Population et methode Il s’git d’une etude retrospective sur 10 ans des SBS signales aux tribunaux de grande instance (TGI) de Rennes et Saint-Malo. Les dossiers ont ete recenses a partir des archives du departement d’information medicale, de la cellule d’accueil specialise de l’enfance en danger et du service de medecine legale du centre hospitalier universitaire (CHU) de Rennes. Les dossiers judiciaires ont ete consultes apres accord des procureurs de la Republique. Resultats Sur 34 dossiers inclus, 12 n’ont pu etre consultes, 16 avaient abouti a un classement sans suite ou une ordonnance de non-lieu. Six dossiers ont abouti a une condamnation penale. L’auteur etait le pere (n = 5) ou l’assistante maternelle (n = 1). Il existait 3 jugements sur interets civils dont le montant moyen etait de 3333 euros (ecart-type 2082). Seulement 2 enfants ont ete indemnises par une Commission d’indemnisation des victimes d’infraction (CIVI). Conclusion La majorite des dossiers aboutit a une absence de condamnation et d’indemnisation. Le diagnostic medical de « secousses » et donc la potentielle intervention d’un tiers ne se traduisent pas necessairement par une condamnation penale. La designation systematique d’un administrateur ad hoc pourrait permettre une saisine plus frequente de la CIVI.

Belief in free will has been a mainstay in philosophy throughout history, grounded in large part in our intuitive sense that we consciously control our actions and could have done otherwise. However, psychology and psychiatry have long sought to uncover mechanistic explanations for human behavior that challenge the notion of free will. In recent years, neuroscientific discoveries have produced a model of volitional behavior that is at odds with the notion of contra-causal free will and our sense of conscious agency. Volitional behavior instead appears to have antecedents in unconscious brain activity that is localizable to specific neuroanatomical structures. Updating notions of free will in favor of a continuous model of volitional self-control provides a useful paradigm to conceptualize and study some forms of psychopathology such as addiction and impulse control disorders. Similarly, thinking of specific symptoms of schizophrenia as disorders of agency may help to elucidate mechanisms of psychosis. Beyond clinical understanding and etiological research, a neuroscientific model of volitional behavior has the potential to modernize forensic notions of responsibility and criminal punishment in order to inform public policy. Ultimately, moving away from the language of free will towards the language of volitional control may result in an enhanced understanding of the very nature of ourselves.

Resume L’introduction en 1993 en France de la vaccination contre Haemophilus influenzae de serotype b (Hib) a permis une reduction rapide du nombre des cas d’infections invasives dues a cette espece. Pourtant, malgre une dose de rappel, la survenue d’une meningite a Hib reste possible, bien qu’exceptionnelle. Nous rapportons 3 observations de meningites a Hib en saison hivernale entre 2007 et 2010, survenues chez des enfants correctement vaccines, âges de 9, 14 et 29 mois. L’evolution sous traitement a ete favorable pour les 3 enfants et aucun deficit immunitaire n’a ete mis en evidence. Apres 18 annees de vaccination, ces observations mettent en evidence le risque toujours present des meningites a Hib, y compris chez des enfants vaccines, ainsi que la persistance de la circulation des souches dans la population generale.

WOS:000324536200013; International audience; The present study shows no adverse effects of the anti-diabetic drug metformin on bone mass and fracture healing in rodents but demonstrates that metformin is not osteogenic in vivo, as previously proposed. Introduction In view of the increased incidence of fractures in patients with type 2 diabetes mellitus (T2DM), we investigated the effects of metformin, a widely used T2DM therapy, on bone mass and fracture healing in vivo using two different rodent models and modes of metformin administration. Methods We first subjected 12-week-old female C57BL/6 mice to ovariectomy (OVX). Four weeks after OVX, mice received either saline or metformin administered by gavage (100 mg/kg/daily). After 4 weeks of treatment, bone micro-architecture and cellular activity were determined in tibia by micro-CT and bone histomorphometry. In another experiment, female Wistar rats aged 3 months were given only water or metformin for 8 weeks via the drinking water (2 mg/ml). After 4 weeks of treatment, a mid-diaphyseal osteotomy was performed in the left femur. Rats were sacrificed 4 weeks after osteotomy and bone architecture analysed by micro-CT in the right tibia while fracture healing and callus volume were determined in the left femur by X-ray analysis and micro-CT, respectively. Results In both models, our results show no significant differences in cortical and trabecular bone architecture in metformin-treated rodents compared to saline. Metformin had no effect on bone resorption but reduced bone formation rate in trabecular bone. Mean X-ray scores assessed on control and metformin fractures showed no significant differences of healing between the groups. Fracture callus volume and mineral content after 4 weeks were similar in both groups. Conclusions Our results indicate that metformin has no effect on bone mass in vivo or fracture healing in rodents.

The development of an automatic telemedicine system for computer-aided screening and grading of diabetic retinopathy depends on reliable detection of retinal lesions in fundus images. In this paper, a novel method for automatic detection of both microaneurysms and hemorrhages in color fundus images is described and validated. The main contribution is a new set of shape features, called Dynamic Shape Features, that do not require precise segmentation of the regions to be classified. These features represent the evolution of the shape during image flooding and allow to discriminate between lesions and vessel segments. The method is validated per-lesion and per-image using six databases, four of which are publicly available. It proves to be robust with respect to variability in image resolution, quality and acquisition system. On the Retinopathy Online Challenge's database, the method achieves a FROC score of 0.420 which ranks it fourth. On the Messidor database, when detecting images with diabetic retinopathy, the proposed method achieves an area under the ROC curve of 0.899, comparable to the score of human experts, and it outperforms state-of-the-art approaches.

stable in 5% of cases, worst in 43% of cases. Conclusions: Our study confirms that hypernatremia is a situation known in less than 1% of patients admitted to the emergency department. It mostly happens with old patients, with cognitive disorders, and generally it is associated with extracellular dehydration. Most of the times, the admission’s reason to the emergency is confused with the cause of hypernatremia. The mortality of hypernatremic patients is important because of underlying comorbidities and the reason for admission to the emergency. After one day of hospitalization, 43% of patients have serum sodium higher than at the entrance. The factors which increase the natremia are numerous: inadequate choice for the rehydration fluid, no calculation of water deficit, less prescription by prescriber (rate). Hypernatremia is a situation related with a significant mortality. The emergency management of hypernatremia has to be improved. Several factors lead to the aggravation of the hypernatremia during the first 24 hours for some patients.

Over the past 60 years, the Diagnostic and Statistical Manual of Mental Disorders (DSM) has evolved from early efforts to collect statistical information to a modern compendium of mental disorders that can be reliably diagnosed, but have not been validated. Throughout this history, DSM architects have struggled with the seemingly fundamental, but complex question of how to define a mental disorder. Current proposals indicate that a spectrum model of mental illness will be embraced in DSM-5, prompting renewed concern and debate about pathologizing normal existence. While a spectrum view of mental illness may reflect biologic reality and help pave the path towards validated models of psychiatric disorder, diagnostic expansion does have important practical implications and could give rise to problems in clinical work and society at large, including the further sanctioning of a shift from psychiatric treatment to neuroenhancement. Debates about what should or should not be considered a mental illness in DSM-5 are likely to remain unresolved and, in the future, must be framed according to contextual utility. Diagnosis and thresholds of pathology are ultimately value-based so that careful analysis and perhaps even different definitions of disorder may be required to guide decision-making in research, clinical work, and public policy.

While auditory hallucinations (AH) are prototypic psychotic symptoms whose clinical presence is often equated with a psychotic disorder, they are commonly found among those without mental illness as well as those with nonpsychotic disorders not typically associated with hallucinations in DSM-IV. This incongruity presents a significant challenge for clinical work and efforts to revise the next iteration of the DSM. Auditory hallucinations found among "normal" people suggest that either AH are not as pathologic as they are typically taken to be, or that less-than-hallucinatory experiences are routinely mischaracterized as AH. Such hallucinations in the context of conversion disorder, trauma, sensory deprivation, and certain cultural settings strengthen an association between AH and psychopathology but suggest limited diagnostic specificity and relevance. It may be useful to think of AH like coughs-common experiences that are often, but not always, symptoms of pathology associated with a larger illness. Although these issues have been known for many years, they are rarely discussed in American psychiatry and need to be addressed in future research and clinical work.

In this study, we demonstrate that gamma oscillations (30–50 Hz) recorded in the local field potentials (LFP) of the hippocampus are a marker of temporal lobe seizure propagation and that the level of LFP synchrony in the amygdalo-hippocampal network, during these oscillations, is related to the severity of seizures. Sprague–Dawley rats were given a single systemic dose of kainic acid (KA; 6 mg/kg, i.p.) and local field potential activity (1–475 Hz) of the dorsal hippocampus, the amygdala and the neocortex was recorded. Of 135 ictal discharges, 55 (40.7%) involved both limbic structures. We demonstrated that 78.2% of seizures involving both the hippocampus and amygdala showed hippocampal gamma oscillations. Seizure duration was also significantly correlated with the frequency of hippocampal gamma oscillations (r2=0.31, p

Considerable effort is focused on a revised definition of schizophrenia for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) anticipated in 2012. Among the core debates are how to define a disorder without an established pathophysiology, whether diagnosis is improved by implementing continuous symptomatic dimensions, and to what extent neurocognitive deficits should be integrated into schizophrenia for DSM-V. Although lacking in validity, the diagnosis "schizophrenia" remains a useful term for clinical communication, with current antipsychotic therapies encouraging diagnostic "lumping" rather than "splitting." Much evidence supports a move to a dimensional model for psychosis, but doing so raises the potential for overdiagnosis. Validity problems exist not only with schizophrenia, but also with its defining symptoms such as delusions and hallucinations. Integrating dimensional symptom clusters into DSM-V schizophrenia, exemplified by models based on neurocognitive defic...

Hepatitis B and C are public health problems. Psychiatric patients may be at risk of hepatitis B and C exposure due to lifestyle and inadequate health care. We aimed to determine prevalence of hepatitis B and C virus exposure and associated risk factors in acutely hospitalized psychiatric veterans. A total of 234 individuals consecutively admitted to the psychiatric wards at the West Los Angeles Veterans Affairs Hospital were asked to participate. A total of 129 patients consented and were screened for viral hepatitis risk factors, hepatitis B surface antigen, hepatitis B surface and core antibodies, and hepatitis C antibodies. About 31 and 38% of the patients had been exposed to hepatitis B and C viruses, respectively. Several risk factors were associated with exposure. Inpatient psychiatric veterans seem to have increased rates of hepatitis B and C exposure. This highlights the need for prevention of risk behavior in this vulnerable population.

People with schizophrenia commonly lack insight, that is, they are unaware of their illness and the consequences thereof. One of the most important consequences of lack of insight is a failure to recognise the need for treatment, leading to treatment nonadherence. With several scales that now enable objective measurement of insight, it is possible to examine correlates of insight change, including course of illness and treatment adherence. Specific interventions, both pharmacological and psychotherapeutic, have been developed to enhance illness insight and treatment adherence. The extent to which second-generation antipsychotic medications, including a recently released long-acting formulation, improve insight and/or enhance treatment adherence remains to be determined.

The metabolic syndrome has become a focus of clinical attention due to its high prevalence in the United States (23%) and impact on cardiovascular risk, yet limited data exist on the prevalence of this syndrome among U.S. veterans with schizophrenia.A convenience sample of patients diagnosed with schizophrenia or schizoaffective disorder was obtained from inpatient units and outpatient clinics at Veterans Affairs medical centers in San Diego and Los Angeles.In this predominantly male (92.5%) sample of 80 veterans, with mean age of 49.0 years, the age-adjusted prevalence of the metabolic syndrome was 51.2%, more than twice the age-adjusted prevalence in the general U.S. population. The female cohort was small (n = 6), but had a greater mean body mass index and higher prevalence of metabolic syndrome than the male subjects.The metabolic syndrome is highly prevalent in this sample of patients with schizophrenia and represents an enormous source of cardiovascular disease risk. Clinicians who treat patients with schizophrenia should monitor for the parameters that define the metabolic syndrome as part of the ongoing management of patients treated with antipsychotics.

During 2003, a portable instrument suite was used to conduct cosmic radiation measurements on 49 jet-altitude flights, which brings the total number of in-flight measurements by this research group to over 160 flights since 1999. From previous measurements, correlations have been developed to allow for the interpolation of the dose-equivalent rate for any global position, altitude and date. The result was a Predictive Code for Aircrew Radiation Exposure (PCAIRE), which has since been improved. This version of the PCAIRE has been validated against the integral route dose measurements made at commercial aircraft altitudes during the 49 flights. On most flights, the code gave predictions that agreed to the measured data (within +/- 25%), providing confidence in the use of PCAIRE to predict aircrew exposure to galactic cosmic radiation. An empirical correlation, based on ground-level neutron monitoring data, has also been developed for the estimation of aircrew exposure from solar energetic particle (SEP) events. This model has been used to determine the significance of SEP exposure on a theoretical jet altitude flight during GLE 42.

The treatment of schizophrenia changed drastically with the discovery of antipsychotic medications in the 1950s, the release of clozapine in the US in 1989 and the subsequent development of the atypical or novel antipsychotics. These newer medications differ from their conventional counterparts, primarily based on their reduced risk of extrapyramidal symptoms (EPS). EPS can be categorised as acute (dystonia, akathisia and parkinsonism) and tardive (tardive dyskinesia and tardive dystonia) syndromes. They are thought to have a significant impact on subjective tolerability and adherence with antipsychotic therapy in addition to impacting function. Unlike conventional antipsychotic medications, atypical antipsychotics have a significantly diminished risk of inducing acute EPS at recommended dose ranges. These drugs may also have a reduced risk of causing tardive dyskinesia and in some cases may have the ability to suppress pre-existing tardive dyskinesia. This paper reviews the available evidence regarding the incidence of acute EPS and tardive syndromes with atypical antipsychotic therapy. Estimates of incidence are subject to several confounds, including differing methods for detection and diagnosis of EPS, pretreatment effects and issues surrounding the administration of antipsychotic medications. The treatment of acute EPS and tardive dyskinesia now includes atypical antipsychotic therapy itself, although other adjunctive strategies such as antioxidants have also shown promise in preliminary trials. The use of atypical antipsychotics as first line therapy for the treatment of schizophrenia is based largely on their reduced risk of EPS compared with conventional antipsychotics. Nevertheless, EPS with these drugs can occur, particularly when prescribed at high doses. The EPS advantages offered by the atypical antipsychotics must be balanced against other important adverse effects, such as weight gain and diabetes mellitus, now known to be associated with these drugs.

This article has reviewed the emerging side-effect profiles of second-generation antipsychotic medications. Although these medications have favorable extrapyramidal side-effect profiles, clinicians must be aware of their propensity to cause weight gain, glucose and lipid abnormalities, and cardiac and sexual side effects. If clinicians are proactive about warning patients about these side effects and appropriately monitoring them, further morbidity and mortality may be prevented in this patient population. Initial choices of medication should be made based on the relative side-effect profiles in light of a particular patient's medical status. In the future, new treatments may be developed, with even fewer side effects.

To prospectively determine the accuracy of computed tomography (CT) in the detection of painful infection at the site of hip prosthesis before surgery.Helical CT examinations of hip prostheses were prospectively performed before surgery after a standard clinical and radiologic examination of 65 patients. CT scans and conventional radiographs were reviewed for periprosthetic bone abnormalities, and CT scans were reviewed for periprosthetic soft-tissue abnormalities (joint distention, fluid-filled bursae, and fluid collection in muscles and perimuscular fat). Patients subsequently underwent revision arthroplasty within 1 month, and infection was diagnosed in 12 (19%) patients.Infection was detected clinically in 25% of patients. Periprosthetic bone abnormalities did not allow differentiation of infection from complications not related to sepsis, except for periostitis, with 100% specificity but only 16% sensitivity. Soft-tissue findings were accurate for detection of infection, with 100% sensitivity and 87% specificity. Fluid collection in muscles and perimuscular fat had a 100% positive predictive value, and absence of joint distention had a 96% negative predictive value.CT is accurate in the diagnosis of painful infection at the site of a hip prosthesis on the basis of soft-tissue findings, whereas periprosthetic bone abnormalities are not useful.

Background : The novel antipsychotic medications offer a more favorable extrapyramidal side effect profile than conventional agents. It is uncertain that the novel antipsychotics have a benefit in terms of sexual side effects. Methods : We prospectively administered a survey of sexual functioning to 25 male patients with DSM-IV schizophrenia, taking conventional and novel antipsychotics. Contrasts were made between three treatment groups: clozapine (CLOZ), risperidone (RIS), and a combined haloperidol/fluphenazine (HAL/FLU) group. Results : A decrease in overall sexual functioning was reported in all medication groups (40–71%). The majority of subjects taking RIS or HAL/FLU reported a decline in one or more aspects of sexual functioning. Examining specific aspects of sexual functioning revealed that, a decline in sexual interest was significantly less common on CLOZ compared to RIS (0 vs. 64%; χ 2 =6.1, df=1, p =0.01) or HAL/FLU (0 vs. 67%; χ 2 =5.2, df=1, p =0.02), while a decline in the erectile frequency was significantly more common on RIS compared to CLOZ (40 vs. 93%; χ 2 =6.2, df=1, p =0.01) or HAL/FLU (50 vs. 93%; χ 2 =4.8, df=1, p =0.03) (0%). For enjoyment of orgasm and ejaculatory volume, significantly fewer CLOZ compared to RIS subjects reported a decline (20 vs. 86%; χ 2 =7.4, df=1, p =0.01). Conclusions : Sexual side effects are common clinically pertinent adverse effects associated with both novel and conventional antipsychotic medications. They deserve increased attention in clinical work and future research with emerging antipsychotic drugs.

The novel antipsychotic drugs offer significant advantages over conventional antipsychotic drugs because of their favorable extrapyramidal side-effect profiles. These medications do have some side effects that are clinically significant to our patients with psychotic disorders, however. We summarize

Center, Greater Los Angeles, CA; Hollie A. L. Gelberg, PhD, RD, clini Medical Center, Greater Los Angeles, CA; Jennifer A. Rosen, PharmD PGY-2 pharmacy residency program director in psychiatry, Departmen Long Beach, CA; Valery Chamberlin, MD, co-investigator, Sepulveda UCLA, and associate residency director, UCLA-SFV Psychiatry, Departm Chandresh Shah, MD, co-investigator, Los Angeles Ambulatory Care Veterans Affairs Medical Center, Greater Los Angeles, CA; Charles N Mental Health, Department of Veterans Affairs Medical Center, Long Angeles VA, associate director of residency education, UCLA Semel In co-chief, Schizophrenia Treatment Unit, West Los Angeles VA Medica chiatry & Biobehavioral Sciences, David Geffen School of Medicine at Los Angeles, CA; Zachary D. Erickson, program manager, Medical Re Los Angeles, CA; Shirley J. Mena, MSN, RN, research assistant, Med Greater Los Angeles, CA; Michael King, Jr, research assistant, Medic Greater Los Angeles, CA; Irina Arnold, MS, MD (MD obtained in Russia Affairs Medical Center, Greater Los Angeles, CA; Matthew R. Baker, Affairs Medical Center, Greater Los Angeles, CA; Hilary B. Meyer, resea Medical Center, Greater Los Angeles, CA; and Donna Ames, MD, pri tation and Recovery Center, and professor in residence, David Geffen Medical Center, Greater Los Angeles, CA.

Defining the borders of mental illness is challenging due to the lack of established validity for psychiatric disorders, a diagnostic system based largely on reported symptoms, and the highly subjective nature of distress and functional impairment. Consequently, debates about the potential perils of overdiagnosis (e.g., false positives) and underdiagnosis (e.g., false negatives) with new diagnostic revisions are ongoing as we prepare for the release of DSM-5. Such debates are rooted in the many different and often conflicting applications of psychiatric diagnosis, with clinical work generally favoring lowered diagnostic thresholds on the one hand and the work of rationing of healthcare resources necessitating higher thresholds on the other. Deciding what should or should not be considered a mental disorder in DSM can only be resolved by a pragmatic analysis of contextual utility. A philosophically satisfying, scientifically grounded, and economically viable model of future psychiatry should more formally acknowledge a continuum of mental illness and mental health, apply research evidence-based guidelines regarding optimal interventions along this continuum rather than assuming pharmacotherapy is a panacea, and concede that specialty care provided by psychiatrists must be integrated within the larger scope of mental health care.

During the past century, the scope of mental health intervention in North America has gradually expanded from an initial focus on hospitalized patients with psychoses to outpatients with neurotic disorders, including the so-called worried well. The Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, is further embracing the concept of a mental illness spectrum, such that increasing attention to the softer end of the continuum can be expected in the future. This anticipated shift rekindles important questions about how mental illness is defined, how to distinguish between mental disorders and normal reactions, whether psychiatry is guilty of prevalence inflation, and when somatic therapies should be used to treat problems of living. Such debates are aptly illustrated by the example of complicated bereavement, which is best characterized as a form of adjustment disorder. Achieving an overarching definition of mental illness is challenging, owing to the many different contexts in which DSM diagnoses are used. Careful analyses of such contextual utility must inform future decisions about what ends up in DSM, as well as how mental illness is defined by public health policy and society at large. A viable vision for the future of psychiatry should include a spectrum model of mental health (as opposed to exclusively mental illness) that incorporates graded, evidence-based interventions delivered by a range of providers at each point along its continuum.

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM – whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part 1 of this article took up the first two questions. Part 2 took up the second two questions. Part 3 now deals with Questions 5 & 6. Question 5 confronts the issue of utility, whether the manual design of DSM-III and IV favors clinicians or researchers, and what that means for DSM-5. Our final question, Question 6, takes up a concluding issue, whether the acknowledged problems with the earlier DSMs warrants a significant overhaul of DSM-5 and future manuals. As in Parts 1 & 2 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.