François Ducrocq

Immediate treatment with propranolol decreases posttraumatic stress disorder two months after trauma

BACKGROUND This study investigated the efficacy of propranolol prescribed shortly after trauma exposure in the prevention of posttraumatic stress disorder (PTSD) symptoms and diagnosis. METHODS Eleven patients received 40 mg of propranolol 3 times daily for 7 days, followed by a taper period of 8-12 days. They were compared with eight patients who refused propranolol but agreed to participate in the study. Though nonrandomized, the two groups did not differ on demographics, exposure characteristics, physical injury severity, or peritraumatic emotional responses. RESULTS Posttraumatic stress disorder rates were higher in the group who refused propranolol (3/8) compared with those who received the medication (1/11), as were the levels of PTSD symptoms (U = 85, p =.037). CONCLUSIONS Our results are consistent with earlier findings and suggest that propranolol may be useful for mitigating PTSD symptoms or perhaps even preventing the development of PTSD.

ALGOS: the development of a randomized controlled trial testing a case management algorithm designed to reduce suicide risk among suicide attempters.

BackgroundSuicide attempts (SA) constitute a serious clinical problem. People who attempt suicide are at high risk of further repetition. However, no interventions have been shown to be effective in reducing repetition in this group of patients.Methods/DesignMulticentre randomized controlled trial.We examine the effectiveness of «ALGOS algorithm»: an intervention based in a decisional tree of contact type which aims at reducing the incidence of repeated suicide attempt during 6 months. This algorithm of case management comprises the two strategies of intervention that showed a significant reduction in the number of SA repeaters: systematic telephone contact (ineffective in first-attempters) and «Crisis card» (effective only in first-attempters). Participants who are lost from contact and those refusing healthcare, can then benefit from «short letters» or «postcards».DiscussionALGOS algorithm is easily reproducible and inexpensive intervention that will supply the guidelines for assessment and management of a population sometimes in difficulties with healthcare compliance. Furthermore, it will target some of these subgroups of patients by providing specific interventions for optimizing the benefits of case management strategy.Trial RegistrationThe study was registered with the ClinicalTrials.gov Registry; number: NCT01123174.

Low posttrauma GABA plasma levels as a predictive factor in the development of acute posttraumatic stress disorder

BACKGROUND Gamma amino-butyric acid (GABA) regulates the intensity and the duration of the central hyperadrenergic response in times of high stress and has been negatively associated with anxiety, depression, and sleep problems. We hypothesized that individuals with low plasma GABA levels may be more prone to develop posttraumatic stress disorder (PTSD) in the aftermath of trauma exposure. METHODS To test this hypothesis, we measured plasma GABA levels in a population of 108 road traffic accident victims on arrival at a traumatology department and assessed them for PTSD 6 weeks later. RESULTS The mean GABA level (nmol/mL) in the PTSD group (n = 55; M =.20; SD =.08) was significantly lower compared with members of the trauma-exposed group who did not develop PTSD [n = 17; M =.30; SD =.09), t(70) = 3.94, p =.0002]. CONCLUSIONS Provided that GABA levels in the brain are genetically predetermined, our results would suggest that individuals with low plasma GABA levels are premorbidly more vulnerable to stress-related disorders such as acute PTSD. If replicated, plasma GABA levels measured in the aftermath of trauma exposure might help to identify individuals at high risk for developing PTSD.

Temporal analysis of heart rate variability as a predictor of post traumatic stress disorder in road traffic accidents survivors

BACKGROUND Road Traffic Accidents (RTA) are most probably the leading cause of post traumatic stress disorder (PTSD) in developed countries. The autonomic nervous system (ANS) disturbances, due to psychological trauma, are part of the pathophysiology of PTSD. The aim of the present study was to determine whether early heart rate variability (HRV) measurement, a biomarker of the ANS function, could act as a predictor of PTSD development after a RTA. METHODS We prospectively investigated 35 survivors of RTA with both physical injury and psychological trauma. HRV data were obtained from 24-h Holter ECG monitoring, which was performed on the second day after the accident. Time domain analysis was applied to the inter-beat (RR) interval time series to calculate the various parameters of HRV. PTSD status was assessed 2 and 6 months after RTA. RESULTS There was a global diminution of HRV measurements in the PTSD group at both 2 and 6 months. The variability index was the best predictor of PTSD with the area under the receiveroperating curve for discriminating PTSD at 6 months at 0.92 (95% CI: 0.785; 1.046). A cut-off at 2.19% yielded a sensitivity of 85.7% and a specificity of 81.8% for PTSD. Positive and negative predictive values were respectively 75% and 90%. However, initial heart rate (HR) data were relevant at 2 months but not at 6 months. CONCLUSION RTA survivors exhibiting lower parasympathetic modulation of HR, indexed by temporal analysis of HRV, are more susceptible to developing PTSD as a short and long-term outcome.

Categorical and dimensional study of the predictive factors of the development of a psychotrauma in victims of car accidents.

OBJECTIVE This study aimed to evaluate the predictive factors of the emergence of complete PTSD and subsyndromal PTSD (defined as individuals exposed to a traumatic event with at least one psychopathological impact, such as hyperarousal, avoidance or persistent re-experiencing) following a motor vehicle accident (MVA). METHODS We recruited 155 adult MVA patients, physically injured and admitted to trauma service, over two years. In the week following the accident, patients were asked to complete questionnaires assessing their social situation (sex, age, marital and employment status, prior MVA or trauma), comorbidity (MINI), distress (PDI) and dissociation (PDEQ) experienced during and immediately after the trauma. An evaluation using the CAPS was conducted six months after the trauma to assess a possible PTSD. RESULTS At six months, 25.8% of the participants developed subsyndromal symptoms and 7.74% developed complete PTSD. The three symptoms that best discriminated the groups were dysphoric emotion, perceived life threat and dissociation. Logistic regression results showed that the strongest predictor of PTSD was the perceived life threat. In addition, a dimensional approach to the results revealed significant correlations between (1) peritraumatic distress and persistent re-experiencing or hyperarousal and (2) dissociation score and avoidance strategy. The presence of a prior traumatic event reinforces avoidance strategies. CONCLUSIONS Our results stress that peritraumatic factors (especially the perception of a life threat) are good predictors of PTSD development. A dimensional perspective allows better identification of psychological complications following an MVA.

Prediction of trauma-related disorders: a proposed cutoff score for the peritraumatic distress inventory.

In the month following a motor vehicle accident, the rate of posttraumatic stress disorder (PTSD) and other trauma-related disorders (ie, mood, other anxiety disorders, and substance use disorders) may reach 30%.1 From a clinical perspective, there is an unmet need to develop screening tools that can help identify individuals at risk of developing such disorders. The Peritraumatic Distress Inventory (PDI) is a 13-item self-report measure—validated in several languages—that has been shown in several studies to predict the development of posttraumatic stress symptoms or disorder.2–4 In a prospective study of 79 motor vehicle accident victims, Nishi et al5 proposed an optimum cutoff point of 23 for the PDI to predict acute PTSD 1 month after the accident. However, to this day, the measure has not been used to predict the full spectrum of trauma-related disorders. The aim of this study was to fill that gap. Method. The study, approved by an independent ethics committee, included 211 subjects consecutively hospitalized in a Trauma Center following a motor vehicle accident from January 2003 to July 2006. The PDI was administered within 5 days of admission after written informed consent was obtained. Six weeks after the accident, the patients underwent a semistructured PTSD diagnostic interview6 as well as the Mood, Anxiety, and Substance Use Disorders sections of a structured psychiatric interview7 by trained psychiatrists. Partial PTSD as described by Blanchard et al8 was also screened for. Subjects with a history of posttraumatic amnesia were excluded. Nineteen subjects were lost at the 6-week follow-up and therefore dropped from the analyses. Results. The final cohort consisted of 192 subjects, 137 adult men and 55 women. The mean age of subjects was 35.14 years (SD = 15.39). Injury severity was classified as mild (10%), moderate (49%), or severe (41%). In the final cohort, 154 subjects fulfilled DSM-IV-TR criteria A1 and A2 for trauma exposure. The mean PDI total score was 15.68 (SD = 8.71). At the follow-up, 66 patients fulfilled criteria for partial (n = 31) or full (n = 35) PTSD, 19 for major depressive disorder, 10 for at least 1 anxiety disorder, and 3 for a psychoactive substance disorder. No association was found between injury severity and PTSD (χ2 = 0.96, df = 1, NS). The PDI score was, however, significantly associated with an increased risk of acute PTSD (χ2 = 5.15, df = 1, P = .02). According to the occurrence of traumatic events, receiver operating characteristic curve analysis showed an area under the curve (AUC) of 0.7 (Figure 1). The optimum predictive cutoff point of the PDI was a score of 14 (sensitivity 68%, specificity 61%). On the one hand, 90% of the victims with a PDI score > 28 developed PTSD or partial PTSD at follow-up. On the other hand, 90% of those with a score < 7 did not develop PTSD. In order to detect PTSD or partial PTSD 6 weeks later, we propose a cutoff score of 14 (PTSD: sensitivity 84% and specificity 47%, AUC 0.6; partial PTSD: sensitivity 73% and specificity 60%, AUC 0.7). Figure 1 Receiver Operating Characteristic (ROC) Curve for Occurrence of PTSD and PDI Scorea The PDI could be a useful tool for screening individuals at risk of developing trauma-related disorders. We recommend that trauma survivors with a PDI score 28 would need immediate care and follow-up. Finally, for those with a score of 7 through 28, we propose a checkup after a few weeks.

Les appels au Samu pour tentative de suicide peuvent-ils être utilisés pour apprécier le nombre de tentatives de suicide dans une population ?

[1] Dallot A, Carlotti A, Lipsker D. Vascularites. Ann Dermatol Venereol 2009;136:168-74. [2] Isabell M, Stephane M, Jacques B, Vanessa G, Herve L. Influence de l’âge sur les caractéristiques des purpuras vasculaires : 132 patients. Presse Med 2010;39:e247-57. [3] Alric L, Chauvet E, Toulemonde P, Duffaut M. Infection à Rhodoccocus equi : une cause rare de vascularite cutanée. Rev Med Interne 2002; 23:569-71. [4] Bourée P, Bisaro F, Resende P. Actinomycose : du saprophytisme à la pathogénicité. Antibiotiques 2009;11:142-9. [5] Miller M, Haddad AJ. Cervicofacial actinomycosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:496-508. [6] Hall V. Actinomyces – Gathering evidence of human colonization and infection. Anaerob 2008;14:1-7. [7] Liotier J, Venet C, Chambonnière ML, Fournier C, Fotso MJ, Ewencsyk I, Barral FG, Carricajo A, Robert F, Lucht F, Mosnier JF, Zéni F. Abcès cérébraux multiples à Actinomyces. Presse Med 2004;33:318-20. [8] Marius I, Véronique H, Catherine B, Sandra L, Paul H. Caractéristiques morphologiques et principales étiologies des infections rhino-sinusiennes. Ann Pathol 2009;29:313-22. [9] Sinzelle E, Alexandre I, Aziza G, Couzigou C, Bellin MF. Un cas d’actinomycose pelvienne : aspect scannographique et en imagerie par résonance magnétique. J Radiol 2009;90:1859-61. [10] Acevedo F, Baudrand R, Letelier LM, Gaete P. Actinomycosis: a great pretender. Case reports of unusual presentations and a review of the literature. Int J Infect Dis 2008;12:358-62. [11] Russo T. Actinomycosis. In: Kasper DL, editor. Harrison’s principles of internal medicine. 16th ed, USA: McGraw-Hill; 2005. p. 937-9.

Particularités de l’état de stress post-traumatique de la personne âgée

(1) Unité de Psychiatrie et Psychotraumatologie, Hôpital Universitaire Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France. (2) Praticien Hospitalier, Service Hospitalo-universitaire, Unité Lafarge B, Centre Hospitalier Esquirol, 15, rue du Docteur Marcland, 87025 Limoges. (3) Cellule d’Urgence Médico-Psychologique Nord-Ouest, SAMU régional de Lille, CHRU de Lille, 59037 Lille cedex, France. (4) Centre d’Accueil et de Crise, Pôle des Urgences, INSERM U513/GIS Épidémiologie en Santé Mentale, Hôpital Michel-Fontan, CHRU de Lille, rue André Verhaegue, 59037 Lille cedex, France. (5) Laboratoire Éthique Médicale et de Médecine légale,Faculté de Médecine Paris V, 45, rue des Saints-Pères, 75006 Paris. INTRODUCTION

Can We Define Termination Of Resuscitation Criteria In Out-Of-Hospital Hanging?

Abstract Objective: Survival rate of cardiac arrest due to hanging (H-CA) victims is low. Hence, this leads to the question of the utility of resuscitation in these patients. The objective was to investigate whether there are predictive criteria for survival with a good neurological outcome or predictive criteria for non-survival or survival with a poor neurological outcome enabling us to define the termination of resuscitation rules in these patients. Methods: Between July 1, 2011 and January 1, 2016, we included 1,689 out-of-hospital cardiac arrests due to hanging. We compared the characteristics of survivors with a good neurological outcome at day 30 with the others. Results: The study population was mainly composed of males with a median age of 48 [37–60]. The overall survival was 2.1%, among which 48.6% had a good neurological outcome. Survivors benefited more often from immediate basic life support than the rest of the subjects, which was corroborated by the shorter no-flow durations. We did not record any difference in terms of advanced cardiac life support initiation frequency and technique between survivors with a good neurological outcome and the rest. Nevertheless, ACLS duration was longer in survivors with a good neurological outcome than in others. Conclusions: Basic life support (BLS) was the decisive criterion for 15/17 survivors. However, a detailed analysis showed 2 survivors presenting no BLS before the arrival of mobile medical teams and non-shockable rhythms who survived at day 30 with a good neurological outcome. These results lead us to consider that mobile medical team intervention and ACLS attempt are not futile, and the benefit justifies the cost. Thus, we cannot define any rule for the termination of resuscitation.

Combining brief contact interventions (BCI) into a decision-making algorithm to reduce suicide reattempt: the VigilanS study protocol

Introduction The early postattempt period is considered to be one of the most at-risk time windows for suicide reattempt or completion. Among the postcrisis prevention programmes developed to compensate for this risk, brief contact interventions (BCIs) have been proven to be efficient but not equally for each subpopulation of attempters. VigilanS is a region-wide programme that relies on an algorithmic system to tailor surveillance and BCI provisions to individuals discharged from the hospital after a suicide attempt. Aim VigilanS’ main objective is to reduce suicide and suicide reattempt rates both at the individual level (patients included in VigilanS) and at the populational level (inhabitants of the Nord–Pas-de-Calais region). Methods and analysis At discharge, every attempter coming from a participating centre is given a crisis card with an emergency number to contact in case of distress. Patients are then systematically recontacted 6 months later. An additional 10-day call is also given if the index suicide attempt is not the first one. Depending on the clinical evaluation during the phone call, the call team may carry out proportionated crisis interventions. Personalised postcards are sent whenever patients are unreachable by phone or in distress. On the populational level, mean suicide and suicide attempt rates in Nord–Pas-de-Calais will be compared before and after the implementation of the programme. Here/there cross-sectional comparisons with a control region will test the spatial specificity of the observed fluctuations, while time-series analyses will be performed to corroborate the temporal plausibility of imputing these fluctuations to the implementation of the programme. On the individual level, patients entered in VigilanS will be prospectively compared with a matched control cohort by means of survival analyses (survival curve comparisons and Cox models). Discussion VigilanS interventional components fall under the ordinary law care regime, and the individuals’ general rights as patients apply with no addendums or restrictions for their participation in the programme. The research section received authorisation from the Ethical Committee of Lille Nord-Ouest under the caption ‘Study aimed at evaluating routine care’ and is registered in ‘Clinical Trials’. The French Ministry of Health plans to extend the experimentation to other regions and probe the relevance of this type of ‘bottom–up’ territorial prevention policy at the national level. Trial registration number NCT03134885.