Fanny Feuillet

Attention deficit hyperactivity disorder among pathological and at-risk gamblers seeking treatment: a hidden disorder.

Background: The links between attention deficit hyperactivity disorder (ADHD) and substance use disorders have been the subject of numerous papers. Few studies, however, have focused specifically on the relationship between ADHD and behavioural addictions. The aim of this study was to (i) examine the frequency of pathological and at-risk gamblers having a previous history of ADHD; (ii) give details of the characteristics of this association, and (iii) identify risk factors for a history of ADHD. Methods: 84 pathological and at-risk gamblers were assessed about socio-demographic, gambling and clinical characteristics. Results: Over 25% of the subjects had a history of ADHD. They were characterized as having more severe gambling problems and a higher level of gambling-related cognitions, a higher frequency of psychiatric comorbidities and an elevated risk of suicide. Finally, they differed in their level and type of impulsivity. Among pathological and at-risk gamblers, a high level of impulsivity, or a history of anxiety disorders, constitute risk factors for a comorbidity with ADHD. Conclusion: The association ‘ADHD-problem gambling’ therefore appears to be not only frequent, but also linked to factors that are known to worsen the prognosis. Researching this relationship is therefore important to adapt strategies for effective future therapy.

Clinical Profiles as a Function of Level and Type of Impulsivity in a Sample Group of At-risk and Pathological Gamblers Seeking Treatment

Level and type of impulsivity are essential variables to be taken into consideration during the initial evaluation of a pathological gambler. The aim of this study was to measure the score for 4 impulsivity-related traits (Urgency, (lack of) Premeditation, (lack of) Perseverance and Sensation seeking) in a sample group of at-risk and pathological gamblers, and to highlight any links with certain elements of clinical data. The UPPS Impulsive Behaviour Scale was administered to 84 problem gamblers seeking treatment. The severity of gambling disorders was evaluated using the diagnostic criteria of the DSM-IV. Psychiatric and addictive comorbidities were also explored. The results indicated that the score for the Urgency facet had a positive correlation with the severity of gambling disorders. It appeared that participants displayed different clinical profiles according to the level and type of impulsivity. Several of the UPPS scales were identified as risk factors for mood disorders, risk of suicide, alcohol use disorders, and Attention Deficit/Hyperactivity Disorder (ADHD). The results confirm both the complexity of the multi-dimensional concept of impulsivity and the reason why the UPPS is of interest for a more in-depth study of the subject.

Implementation of an evidence-based extubation readiness bundle in 499 brain-injured patients. a before-after evaluation of a quality improvement project.

RATIONALE Mechanical ventilation is associated with morbidity in patients with brain injury. OBJECTIVES This study aims to assess the effectiveness of an extubation readiness bundle to decrease ventilator time in patients with brain injury. METHODS Before-after design in two intensive care units (ICUs) in one university hospital. Brain-injured patients ventilated more than 24 hours were evaluated during two phases (a 3-yr control phase followed by a 22-mo intervention phase). Bundle components were protective ventilation, early enteral nutrition, standardization of antibiotherapy for hospital-acquired pneumonia, and systematic approach to extubation. The primary endpoint was the duration of mechanical ventilation. MEASUREMENTS AND MAIN RESULTS A total of 299 and 200 patients, respectively, were analyzed in the control and the intervention phases of this before-after study. The intervention phase was associated with lower tidal volume (P < 0.01), higher positive end-expiratory pressure (P < 0.01), and higher enteral intake in the first 7 days (P = 0.01). The duration of mechanical ventilation was 14.9 ± 11.7 days in the control phase and 12.6 ± 10.3 days in the intervention phase (P = 0.02). The hazard ratio for extubation was 1.28 (95% confidence interval [CI], 1.04-1.57; P = 0.02) in the intervention phase. Adjusted hazard ratio was 1.40 (95% CI, 1.12-1.76; P < 0.01) in multivariate analysis and 1.34 (95% CI, 1.03-1.74; P = 0.02) in propensity score-adjusted analysis. ICU-free days at Day 90 increased from 50 ± 33 in the control phase to 57 ± 29 in the intervention phase (P < 0.01). Mortality at Day 90 was 28.4% in the control phase and 23.5% in the intervention phase (P = 0.22). CONCLUSIONS The implementation of an evidence-based extubation readiness bundle was associated with a reduction in the duration of ventilation in patients with brain injury.

Pharmacoepidemiological characterisation of zolpidem and zopiclone usage

PurposeZolpidem and zopiclone are two widely used non-benzodiazepine hypnotics whose usage seems to be associated to pharmacodependence. However, to our knowledge, there has as yet been no published epidemiological study which has compared their abuse or dependence potential. We used a pharmacoepidemiological approach to identify and characterise zolpidem and zopiclone users in real life situations.MethodsRegular users of zolpidem or zopiclone were identified in the database of a French regional health insurance organisation. A latent class analysis (LCA) was used to identify different subgroups of users of these two hypnotics.ResultsThe study cohort comprised 25,168 patients who regularly used zolpidem and 21,860 who regularly used zopiclone. The results of the latent class analysis, which enables subgroups with similar patterns of response to be identified, revealed four clinical subtypes of users of zolpidem: non-problematic users, users with associations with hypnotics/anxiolytics or with associated mental disorders, and problematic users. Only three subgroups were identified for zopiclone, and LCA did not discriminate a special class of problematic users for this drug.ConclusionOur analysis indicates that there is a subclass of zolpidem user suggestive of abuse; this was not the case for zopiclone. This methodology is very interesting because it allows analysis of databases and determination of a specific signature of drugs potentially leading to abuse or dependence.

Plasma PCSK9 Is a Late Biomarker of Severity in Patients With Severe Trauma Injury

CONTEXT PCSK9 (proprotein convertase subtilisin kexin type 9) is a secreted protease that modulates cholesterol homeostasis by decreasing low-density lipoprotein receptor expression. Low levels of plasma lipoproteins are related to severity of illness and survival in patients of intensive care units (ICU). OBJECTIVE The aim of the study was to investigate the regulation of plasma PCSK9 and its association with plasma lipid parameters and clinical markers of severity during critical illness. DESIGN AND PATIENTS The plasma biobank from the previously published HYPOLYTE prospective study was used to measure PCSK9 concentrations by ELISA at days 0 and 8 in 111 patients admitted to surgical ICU for severe multiple trauma. Patients were randomly assigned to hydrocortisone therapy or placebo. RESULTS Plasma PCSK9 levels were increased by 2-fold between days 0 and 8 (231 ± 116 vs 481 ± 227 ng/ml; P = .0001). Hydrocortisone therapy did not alter PCSK9 concentrations (451 ± 216 vs 511 ± 239 ng/ml in placebo group; P = .33). PCSK9 was positively associated with low-density lipoprotein-cholesterol (Pearson coefficient, 0.26; P = .007) at day 0, but not at day 8. At day 8, an inverse correlation was found between PCSK9 and high-density lipoprotein-cholesterol (β = -653; P = .004). Although baseline PCSK9 concentrations were not associated to severity scores, PCSK9 values at day 8 were related to injury severity score (β = 6.17; P = .0007), length of stay in ICU (β = 6.14; P = .0001), and duration of both mechanical ventilation (β = 8.26; P = .0001) and norepinephrine infusion (β = 18.57; P = .015). CONCLUSIONS Plasma PCSK9 appears as a late biomarker of illness severity in patients with severe multiple trauma.

Effects of tight computerized glucose control on neurological outcome in severely brain injured patients: a multicenter sub-group analysis of the randomized-controlled open-label CGAO-REA study

IntroductionHyperglycemia is a marker of poor prognosis in severe brain injuries. There is currently little data regarding the effects of intensive insulin therapy (IIT) on neurological recovery.MethodsA sub-group analysis of the randomized-controlled CGAO-REA study (NCT01002482) in surgical intensive care units (ICU) of two university hospitals. Patients with severe brain injury, with an expected ICU length of stay ≥48 hours were included. Patients were randomized between a conventional glucose management group (blood glucose target between 5.5 and 9 mmol.L−1) and an IIT group (blood glucose target between 4.4 and 6 mmol.L−1). The primary outcome was the day-90 neurological outcome evaluated with the Glasgow outcome scale.ResultsA total of 188 patients were included in this analysis. In total 98 (52%) patients were randomized in the control group and 90 (48%) in the IIT group. The mean Glasgow coma score at baseline was 7 (±4). Patients in the IIT group received more insulin (130 (68 to 251) IU versus 74 (13 to 165) IU in the control group, P = 0.01), had a significantly lower morning blood glucose level (5.9 (5.1 to 6.7) mmol.L−1 versus 6.5 (5.6 to 7.2) mmol.L−1, P <0.001) in the first 5 days after ICU admission. The IIT group experienced more episodes of hypoglycemia (P <0.0001). In the IIT group 24 (26.6%) patients had a favorable neurological outcome (good recovery or moderate disability) compared to 31 (31.6%) in the control group (P = 0.4). There were no differences in day-28 mortality. The occurrence of hypoglycemia did not influence the outcome.ConclusionsIn this sub-group analysis of a large multicenter randomized trial, IIT did not appear to alter the day-90 neurological outcome or ICU morbidity in severe brain injured patients or ICU morbidity.

A Shorter and Multidimensional Version of the Gambling Attitudes and Beliefs Survey (GABS-23)

The Gambling Attitudes and Beliefs Survey (GABS) is a questionnaire which explores gambling-related dysfunctional beliefs in an unidimensional way. The present research aims to investigate the dimensionality of the scale. 343 undergraduate student gamblers and 75 pathological gamblers seeking treatment completed the GABS and the south oaks gambling screen. Exploratory and confirmatory factor analyses revealed that the original one-factor structure of the GABS did not fit the data effectively. We then proposed a shorter version of the GABS (GABS-23) with a new five-factor structure, which fitted with the data more efficiently. The comparisons between students (problem vs. non-problem gamblers) and pathological gamblers seeking treatment indicated that the GABS-23 can discriminate between problem and non-problem gamblers as efficiently as the original GABS. To ensure the validity and the stability of the new structure of the GABS-23, analyses were replicated in an independent sample that consisted of 628 gamblers (256 non problem gamblers, 169 problem gamblers who are not treatment-seeking and 203 problem gamblers seeking treatment). Analyses showed satisfactory results, and the multidimensional structure of the GABS-23 was then confirmed. The GABS-23 seems to be a valid and useful assessment tool for screening gambling-related beliefs, emotions and attitudes among problem and non-problem gamblers. Moreover, it presents the advantage of being shorter than the original GABS, and of screening irrational beliefs and attitudes about gambling in a multidimensional way. The five-factor model of the GABS-23 is discussed based on the theory of locus of control.

Empiric antimicrobial therapy for ventilator-associated pneumonia after brain injury

Issues regarding recommendations on empiric antimicrobial therapy for ventilator-associated pneumonia (VAP) have emerged in specific populations. To develop and validate a score to guide empiric therapy in brain-injured patients with VAP, we prospectively followed a cohort of 379 brain-injured patients in five intensive care units. The score was externally validated in an independent cohort of 252 brain-injured patients and its extrapolation was tested in 221 burn patients. The multivariate analysis for predicting resistance (incidence 16.4%) showed two independent factors: preceding antimicrobial therapy ≥48 h (p<0.001) and VAP onset ≥10 days (p<0.001); the area under the receiver operating characteristic curve (AUC) was 0.822 (95% CI 0.770–0.883) in the learning cohort and 0.805 (95% CI 0.732–0.877) in the validation cohort. The score built from the factors selected in multivariate analysis predicted resistance with a sensitivity of 83%, a specificity of 71%, a positive predictive value of 37% and a negative predictive value of 96% in the validation cohort. The AUC of the multivariate analysis was poor in burn patients (0.671, 95% CI 0.596–0.751). Limited-spectrum empirical antimicrobial therapy has low risk of failure in brain-injured patients presenting with VAP before day 10 and when prior antimicrobial therapy lasts <48 h. To stop spread of resistant bacteria, we should limit broad antimicrobial therapy in brain-injured pneumonia patients http://ow.ly/UL3pS

Risk factors for prolonged duration of mechanical ventilation in acute traumatic tetraplegic patients—a retrospective cohort study

PURPOSE Respiratory complications constitute an important determinant of length of stay in tetraplegic patients. In a population of tetraplegic patients, we investigated the factors involved in the duration of mechanical ventilation (MV) and whether the duration of MV was associated with the long-term neurologic status. MATERIAL AND METHODS In a retrospective study in 3 intensive care units (ICUs) (January 2001 to December 2009), consecutive patients (≥ 18 years) hospitalized for acute (≤ 24 hours) traumatic tetraplegia were included in the study. Patients with severe brain injury or who died in the first 48 hours were excluded. The primary outcome was the duration of MV. The secondary outcomes were the American Spinal Injury Association (ASIA) motor score on ICU discharge and at 1 year. RESULTS A total of 164 consecutive adult patients with tetraplegia were analyzed. Median (interquartile range) ASIA motor scores were 15 (6-26) on admission, 22 (9-40) on ICU discharge (n = 145 survivors), and 37 (10-80) at 1 year (n = 52 complete follow-up). The median duration of MV was 11 (2-26) days. In multivariate analysis, MV duration increased with pneumonia (P < .0001), atelectasis (P = .0042), and tracheotomy (P < .0001). In exploratory analysis, an increased duration of MV was the only factor associated in multivariate analysis with a low ASIA motor score on ICU discharge (P = .0201) and at 1 year (P = .0003). CONCLUSIONS Prevention of pneumonia and atelectasis is critical for the reduction of MV in tetraplegic patients. Prolonged MV was independently associated with poor neurologic status.

Pharmacoepidemiological characterization of psychotropic drugs consumption using a latent class analysis.

France has one of the highest recorded rates of psychotropic use of drugs compared with other European countries, especially for anxiolytics, hypnotics and antidepressants. The aim of this study was to characterize the use of three psychotropic drugs among the most prescribed in France (bromazepam, paroxetine, zolpidem) using reimbursement databases in real-life conditions. Individuals from a region affiliated to the French General Health Insurance Scheme, who had received at least two dispensings of bromazepam, paroxetine or zolpidem reimbursed between 1 January and 30 June 2008, were included. We used a latent class analysis to identify different subgroups of users for these three psychotropic drugs. A total of 40 644 patients were included for bromazepam, 36 264 for zolpidem and 31 235 for paroxetine. Using latent class analysis, four clinical subtypes of users of bromazepam and zolpidem were identified: nonproblematic users, at-risk users, users with a probable mental disorder and compulsive users. Three subgroups were identified for paroxetine that differed rather by the prescription patterns. Users of anxiolytics and hypnotics with at-risk behaviours represented a significant proportion in the studied population. This original method could be extended to other prescription databases to identify populations at risk of abuse or dependence to psychotropic drugs.