[Transidentites : the relevance of involving psychiatrists]

Psychiatrists play a crucial role in evaluating requests and treatment indications for individuals experiencing gender incongruence, while also providing support throughout the transition process. Their work involves addressing both the psychological and somatic aspects of this journey, facilitating the profound identity changes it entails.

The Impact of the COVID-19 Pandemic on Unassisted Suicide and Assisted Suicide Rates in French-Speaking Switzerland: Differences by Gender

Aims: Most studies on the impact of COVID-19 have shown a decrease or no change in unassisted suicide rates, but effects on assisted suicide have not been studied. We aimed to estimate the association between the COVID-19 pandemic and both types of suicide. Methods: Between 2017 and 2021, 1280 assisted suicides and 535 unassisted suicides were recorded in three Swiss cantons. We conducted descriptive and time series analyses on monthly suicide rates, categorized by gender. Results: Among women, a decrease in assisted suicide rates was found during the acute phases of the pandemic. Among men, assisted suicide rates increased gradually from the onset of the pandemic. Regarding unassisted suicide rates, no significant change was observed in women, while in men, there was a decrease, which was larger at the end than at the onset. Conclusions: COVID-19 had contrasting effects on assisted and unassisted men and women suicide rates.

Oncology clinicians' feelings towards patients presented in supervision: A pre-post assessment using the feeling word checklist

OBJECTIVE

Clinical supervision of oncology clinicians by psycho-oncologists is an important means of psychosocial competence transfer and support. Research on this essential liaison activity remains scarce. The aim of this study was to assess the impact of supervision on oncology clinicians' feelings towards patients presented in supervision.

METHODS

Oncology clinicians' (n = 23) feelings towards patients presented in supervision were assessed with the Feeling Word Checklist (FWC). The FWC was filled in by supervisees prior and after their supervision sessions (n = 91), which were conducted by experienced supervisors (n = 6). Pre- post-modification of feelings was evaluated based on a selection of FWC items, which were beforehand considered as likely to change in a beneficial supervision. Items were evaluated on session level using t-tests for dependent groups. Composite scores were calculated for feelings expected to raise and feelings expected to decrease and analysed on the level of supervisees.

RESULTS

Feelings related to threats, loss of orientation or hostility such as "anxious", "overwhelmed", "impotent", "confused", "angry", "depreciated" and "guilty" decreased significantly after supervision, while feelings related to the resume of the relationship ("attentive", "happy"), a better understanding of the patient ("empathic"), a regain of control ("confident") and being "useful" significantly increased. Feeling "interested" and "calm" remained unchanged. Significant increase or decrease in the composite scores for supervisees confirmed these results.

CONCLUSIONS

This study demonstrates modification of feelings towards patients presented in supervision. This modification corresponds to the normative, formative, and especially restorative function (support of the clinician) of supervision.

Severe post-pyloric injury after button battery ingestion: Systematic literature review and case report

BACKGROUND

The health and safety hazards related to button batteries (BB) have been extensively studied, highlighting that the presence of a button battery in the esophagus is a life-threatening emergency. However, complications related to bowel BB are poorly evaluated and not well known. The objective of this review of the literature was to describe severe cases of BB that have passed the pylorus.

CASE REPORT

This case, from the PilBouTox cohort, is the first report of small-bowel occlusion following ingestion of an LR44 BB (diameter: 11.4 mm) by a 7-month-old infant with a history of intestinal resections. In this case, the BB was ingested without a witness. The initial presentation mimicked acute gastroenteritis evolving into hypovolemic shock. An X-ray revealed a foreign body stuck in the small bowel causing an intestinal occlusion and local necrosis without perforation. The patient's history of intestinal stenosis and intestinal surgery were the contributing factor of impaction.

SYSTEMATIC LITERATURE REVIEW

The review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The research was conducted on September 12, 2022 through five database and the U.S. Poison Control Center website. An additional 12 severe cases of intestinal or colonic injury after ingestion of a single BB were identified. Of these, 11 were related to small BBs (< 15 mm) that impacted Meckel's diverticulum and one was related to postoperative stenosis.

CONCLUSION

In view of the findings, the indications for digestive endoscopy for extraction of a BB in the stomach should include a history of intestinal stenosis or intestinal surgery so as to avoid delayed intestinal perforation or occlusion and prolonged hospitalization.

[Assisted suicide: a need for clarification]

In Switzerland, altruistic assisted suicide is permitted. We present here the federal regulations, the deontological rules, the provisions adopted by the cantons and other requirements applicable to assisted suicide. Given the complexity of these different rules and the legal questions that remain open, we recommend the preparation of brochures for patients, as well as better training and support for people faced with requests for assisted suicide.

Two clinicians for one patient, is it worth it? Patients' perspective on receiving treatment from a pair of clinicians, in a psychiatric emergency and crisis unit

BACKGROUND

In the field of psychiatric crisis interventions, treatment is commonly provided by multidisciplinary teams in Western countries. However, empirical data on the processes involved in this type of intervention are lacking, in particular from a patient perspective. Our study aims to gain a better understanding of the patients' experience of a treatment setting provided by a pair of clinicians in a psychiatric emergency and crisis intervention unit. Patients' perspective could provide a broader understanding of its advantages (or disadvantages), as well as bring new insight on elements influencing patients' treatment adherence.

METHODS

We conducted 12 interviews with former patients treated by a pair of clinicians. The participants' experience, explored with semi-structured questions on their views of the treatment setting, was analyzed by means of thematic analysis using an inductive approach.

RESULTS

The majority of participants experienced this setting as advantageous. A broader comprehension of their issues is the benefit most often expressed. A minority experienced seeing two clinicians as disadvantageous (having to talk to several clinicians at a time, change interlocutors, repeat one's story). Participants attributed joint sessions (with both clinicians) mainly to clinical reasons and separate sessions (with one clinician at a time) mainly to logistical ones.

CONCLUSIONS

This qualitative study provides first insights into patients' experience of a setting including two clinicians providing emergency and crisis psychiatric care. The results show a perceived clinical gain of such a treatment setting for highly in crisis patients. However, further research is needed to evaluate the benefit of this setting, including the indication for joint or separate sessions as the patient's clinical course evolves.

Suicide attempts in LGBTQ+ youth in Switzerland: Qualitative insights in school-based risk factors

Background

Studies show that the LGBTQ+ population is particularly vulnerable to suicidal thoughts and behavior. This vulnerability is even more pronounced in the younger population. However, in Switzerland, qualitative studies on this topic are missing. Our study investigates the processual dynamics and background of suicide attempts of LGBTQ+ youths while looking into their subjective meaning. Here, behaviors of help-seeking are also from interest. In addition, the burdens and resources associated with being LGBTQ+ are explored. By better understanding the process of suicide attempts, we can identify relevant contexts of the respondents’ experiences and illustrate how to enhance suicide prevention strategies. We are referring here to the school context.

Methods

From 2021 until 2024, we interview LGBTQ+ youths in the German- and French-speaking parts of Switzerland who have tried to end their lives between the ages of 14 to 25 (max. three attempts). Applying a multi-perspective approach, we interview persons from their social environment if agreed. Recruitment is based on ‘theoretical sampling’. Data collection and analysis follow the grounded theory methodology. As of July 2022, the sample consists of 18 persons: 3 bisexual women, 1 lesbian woman, 2 gay men, 7 transgender persons, and 5 persons with fluid identities.

Results

Through preliminary analysis, the school context could be identified as one relevant burdening context in the respondents’ experience and suicide attempt process. In this respect, respondents experienced complicated social relationships: e.g., bullying, social exclusion, and pressure to conform. Moreover, the school environment was experienced by some as LGBTQ+ hostile.

Conclusions

Our current findings support the necessity to integrate schools as important stakeholders in suicide prevention but highlight a need for LGBTQ-specific and LGBTQ-sensitive orientations to suicide prevention strategies.

[Health services and systems research in psychiatry - The systemic challenge of the ambulatory shift in psychiatry]

Health services and systems research examines the match between individual and population health needs and clinical services. In the context of the ambulatory shift in psychiatry, services research is important to ensure the quality of clinical developments, their appropriateness to patient and societal needs, their accessibility, efficiency, implementation and real-world outcomes. The purpose of this article is to present the principles that guide mental health services and systems research and to illustrate them with three examples related to the ambulatory shift in psychiatry. Research on services must be based on both epidemiological and clinical research as well as on partnerships with expert patients.

[Relevance of interventions and support for relatives of an individual who made a suicide attempt]

Suicide and suicide attempt has an impact not only on the suicidal individual but also on his relatives. People expose to suicidal behavior of a close relation are confronted to death or to death threat and are subject to various signs such as anxiety, depression, specially linked to trauma. Therefore, it is essential to support those relatives in their suffering. Three types of intervention are distinguished according to timing: immediate, post-immediate and mid-to-long term interventions.

[The health equity issues of an emergency department fee]

In June 2021, the Swiss parliament accepted a legislative proposal calling for the introduction of a fee to fight emergency department (ED) overcrowding. Although this issue remains a major challenge for health policies, the introduction of such a fee raises many questions, notably regarding health equity. However, other more equitable solutions exist: improving the case management of ED frequent users and improving coordination between ED and primary care.

Observational study of suicide in Switzerland: comparison between psychiatric in- and outpatients

AIMS OF THE STUDY

In Switzerland, suicide is a major cause of years of potential life lost. Among people who died by suicide, a significant number suffered from mental illness and were treated by psychiatric care institutions. Psychiatric patients are thus a specific target for suicide prevention. Based on data from a clinical committee reviewing every death by suicide of psychiatric patients in the Canton of Vaud (Switzerland), this observational study aimed to gain knowledge on sociodemographic and clinical characteristics of psychiatric patients who died by suicide by comparing in- and outpatients.

METHODS

Sociodemographic and clinical characteristics of patients who died by suicide in our department from January 2007 to December 2019 were analysed. In- and outpatients were compared.

RESULTS

The sample included 153 patients (64.7% males, n = 99). Three quarters (76.4%, n = 81) of the patients had at least one previous suicide attempt. In- and outpatients did not differ significantly in terms of sociodemographics data, psychiatric diagnosis or method of suicide. Almost all (97.2%) of the outpatients had at least one past psychiatric hospitalisation. We found gender disparities for several variables and a lower male/female suicide ratio than in the general Swiss population. Seventy-two percent of the outpatients (n = 49) had a last personal contact with clinicians less than a week before their suicide and 38.8 % of those less than 24 hours (28% of outpatients, n = 19).

CONCLUSIONS

Patients dying by suicide present most of the time a serious psychiatric history. In- and outpatients seem to have a similar clinical and sociodemographic profile and suicide prevention should thus not be addressed differently in these two groups. The time between death of outpatients and last contact with a therapist was shorter than expected.

[Psychiatric liaison II: training]

Training provided by liaison psychiatry has been considerably developed over the last decades. This article describes how " communication skills" training in oncology evolved to now address interpersonal dimensions of the medical encounter, the clinician's "inner" world and the context. We further present a so-called clinician-centered supervision, which aims to address the intra psychic issues of the clinician; the opportunities and precautions with this specific type of supervision are discussed. Focusing on the clinician facilitates and enriches the clinical encounter and improves medical care.

The Impact of COVID on Adolescent Mental Health, Self-Harm and Suicide: How Can Primary Care Provider Respond? A Position Paper of the European Academy of Pediatrics

Adolescents aged 10 to 19 live a period of their life marked by opportunities and vulnerabilities during which the issue of mental health is of prime importance. Since several decades, and especially since the start of the COVID pandemic, mental health problems and disorders among adolescents have increased around the world. Depression, self-harm and suicidal behavior are common during this period of life, and pediatricians can play a pivotal role in identifying affected or vulnerable youngsters. This article describes risk factors for self-harm and suicidal behavior and reviews how primary care pediatricians and health professionals can respond to such situations. This scoping review is based on existing evidences as well as the authors clinical experience. It suggests concrete actions that can be taken to secure the life of at risk teenagers, and discusses how to organize the transfer to mental health professionals when needed.

[ASSIP: A new therapy following suicide attempt]

Although patients attempting suicide represent a highly vulnerable population, are often reluctant to care and at high risk of repetition, no specific therapy exist for them in French-speaking Switzerland. ASSIP^® (Attempted Suicide Short Intervention Program) fills in this gap. It is a short therapy developed in Bern and being currently implemented in French-speaking Switzerland with the support of the Foundation « Promotion santé suisse » (Swiss health care promotion). ASSIP^® intervention is patient-centered and based on a narrative and behavioral approach and reduces suicide reattempts. It aims to jointly understand patient's suicidal process and to help him/her developing personal strategies to prevent repetition and manage future suicidal crisis.

[The gender paradox in suicide : some explanations and much uncertainty]

Men die more by suicide than women, but women attempt suicide more frequently. Gender does indeed shape suicidal ideas and behaviors. Due to differences in the way men express their suffering, men's depression may be underdiagnosed and undertreated. Furthermore, regarding suicidal behaviors, men use more lethal suicide methods than women. Their suicidal process seems also to progress more rapidly, which is probably related to their frequent substance use. Clinicians and researchers should consider these differences in their approach, without reducing men and women to their gender.

Patients with first versus multiple episodes of self-harm: how do their profiles differ?

BACKGROUND

Self-harm (SH) is among the strongest predictors of further episodes of SH, suicide attempt, and death by suicide. People who repeteadly harm themselves are at even higher risk for suicide. Factors influencing the repetition are important to identify when assessing suicidal risk and thereafter to offer specific interventions. Therefore, this study aimed to compare first versus multiple episodes characteristics in a large sample of patients in french-speaking Switzerland.

METHOD

We used the database from the French-speaking Swiss program for monitoring SH. Data of the psychiatric assessment of all adults admitted for SH were collected in the emergency department of four Swiss city hospitals between December 2016 and October 2019.

RESULTS

1730 episodes of SH were included. Several variables were significantly associated with multiple episodes, including diagnosis (over representation of personality disorders and under representation of anxiety disorders), professional activity (Invalidity insurance more frequent) and prior psychiatry care.

CONCLUSIONS

Patients suffering from a personality disorder and those with invalidity insurance are at risk for multiple episodes of SH and should be targeted with specific interventions.

Patient perspectives on an intervention after suicide attempt: The need for patient centred and individualized care

Background

Many types of intervention exist for suicide attempters, but they tend not to sufficiently consider patient’s views.

Aim

To identify useful components of a previously evaluated intervention after a suicide attempt from the patient’s views and to better understand the process of recovery.

Method

Forty-one interviews with suicide attempters were qualitatively analysed. Views of participants (i) on the components of the intervention (nurse case-management, joint crisis plan, meetings with relatives/network and follow-up calls) and (ii) their recovery were explored. The material was analysed by means of thematic analysis with a deductive-inductive approach.

Results

Participants valued the human and professional qualities of the nurse case-manager, and appreciated follow-up calls and meetings. However, their views diverged regarding for instance frequency of phone calls, or disclosing information or lack thereof. Interpersonal relationship, suicide attempters’ own resources and life changes emerged as core recovery factors.

Discussion

The study highlights the figure of an engaged clinician, with both professional and human commitment, aware that some suicide attempters put more emphasis on their own resources than on delivered health care.

Conclusions

Interventions should consider the clinician as the cornerstone of the tailored care valued by suicide attempters.

[The physician, the clinical practice, and the institution: the suicidal patient]

Patients and their clinical predicaments have an impact on clinicians (that psychoanalysis frames as countertransference), but also on medical institutions. Suicidal patients provide a potent illustration of such phenomena. At the individual level, they evoke intense, often negative affective reactions. At the institutional level, they are also « difficult » patients, who often do not conform to the classical, « expected » sick role. This can result in policies too focused on risk assessment and strict procedures, potentially detrimental to proper care. To prevent such defensive attitudes, institutions should provide clinicians an environment in which they are able to work through their relationships with patients, but also with the medical profession and institutions.

[Physicians, their practice, and the institution : to adapt or to situate oneself ?]

The context of the clinical encounter, and more generally of the practice of medicine, has effects on physicians. For example, it shapes their opinions, discourses, and ultimately their behaviors. The context may also directly impact physicians, sometimes affecting their physical and mental health. Numerous interventions, provided within and outside the institution, are targeting these effects. The question we raise in this article is: should physicians adapt to, or should they rather situate themselves within, their context. This question leads us to discuss reflexivity and reflexivity training.

Countertransference towards suicidal patients: a systematic review

Countertransference towards suicidal patients may blur healthcare professionals’ clinical judgment and lead to suboptimal decision-making. We conducted a systematic review of the quantitative studies on this topic. Following PRISMA guidelines, various databases were searched for studies measuring countertransference in healthcare professionals treating suicidal patients. Two authors independently performed screening and the quality of included studies was formally assessed. Ten studies were identified (3/5/2 of low/intermediate/high quality, respectively). Cross-sectional studies showed evidence for specific and adverse countertransference (e.g., disinterest, anxiety, overwhelming, rejection, helplessness or distress) towards suicidal patients. Furthermore, countertransference was prospectively associated with suicidal behavior and ideation in studies that explored this issue, but the meaning of this association remains to be clarified. Healthcare professionals’ characteristics (e.g. professional background, gender, personality traits) influenced countertransference. Suicidal patients elicit adverse countertransference, which should be addressed in clinical practice and through dedicated training.

Quality of life was similar in children with congenital diaphragmatic hernia and oesophageal atresia and related to respiratory morbidity

AIM

To assess quality of life (QoL) in children with congenital diaphragmatic hernia (CDH) and to compare it with oesophageal atresia (OA).

METHODS

A cross-sectional study in CDH children (≥7 years) was conducted in Lille University Hospital, France, from January 2013 to April 2014. History, lung function (rest, exercise) and Pediatric Quality of Life Inventory questionnaires (PedsQoL 4.0) were collected. Data of OA children were previously published.

RESULTS

Fifty-four CDH patients (male: 53%, median age: 11 years, IQR 9-14) were compared to 54 OA patients (male: 61%, median age: 13 years, IQR: 11-15). CDH children had significantly more frequent history of pneumonia (30% vs 13%), exercise limitation (54% vs 35%) and chest deformity (39% vs 11%); 46% had an obstructive pattern and 66% an abnormal cardiopulmonary exercise test. The median PedsQoL total score in children was 81 (IQR 73-90) in CDH and 81 (IQR 72-91) in OA (P = .8). In CDH, duration of neonatal oxygen therapy, hospitalisation for respiratory disease, exercise limitation, inhaled corticosteroids treatment, chest deformity, abnormal cardiopulmonary exercise test and lower forced expiratory volume in one second were significantly associated with lower QoL scores.

CONCLUSION

PedsQoL scores remained satisfactory in CDH children with CDH, with no difference compared to OA. Patients with respiratory morbidity and lung function impairment, who displayed lower scores, should be identified in order to optimise their management in reference centres.

Harmonized definition of occupational burnout: A systematic review, semantic analysis, and Delphi consensus in 29 countries

Objective:

A consensual definition of occupational burnout is currently lacking. We aimed to harmonize the definition of occupational burnout as a health outcome in medical research and reach a consensus on this definition within the Network on the Coordination and Harmonisation of European Occupational Cohorts (OMEGA-NET).

Methods:

First, we performed a systematic review in MEDLINE, PsycINFO and Embase (January 1990 to August 2018) and a semantic analysis of the available definitions. We used the definitions of burnout and burnout-related concepts from the Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT) to formulate a consistent harmonized definition of the concept. Second, we sought to obtain the Delphi consensus on the proposed definition.

Results:

We identified 88 unique definitions of burnout and assigned each of them to 1 of the 11 original definitions. The semantic analysis yielded a first proposal, further reformulated according to SNOMED-CT and the panelists’ comments as follows: “In a worker, occupational burnout or occupational physical AND emotional exhaustion stateis an exhaustion due to prolonged exposure to work-related problems”. A panel of 50 experts (researchers and healthcare professionals with an interest for occupational burnout) reached consensus on this proposal at the second round of the Delphi, with 82% of experts agreeing on it.

Conclusion:

This study resulted in a harmonized definition of occupational burnout approved by experts from 29 countries within OMEGA-NET. Future research should address the reproducibility of the Delphi consensus in a larger panel of experts, representing more countries, and examine the practicability of the definition.

A Quantitative and Qualitative Study of Notes Left by Youth Who Died by Suicide in Quebec from 1895 to 1985

The study of suicide notes and the evolution of their content could contribute to a better understanding of reasons conducive to suicide mortality and offer further prevention strategies. From 1895 to 1985, 706 coroner's inquests of individuals who died by suicide and were 20 years old or younger were found in the province of Quebec. Quantitative analysis compared those who left notes (n = 47) to those who did not leave notes (n = 659). Furthermore, notes were subjected to inductive thematic analysis. Sociodemographic characteristics of the deceased individuals did not change over time. Qualitative analysis revealed four superordinate themes: (1) last wishes, (2) to those I leave behind, (3) about me and how and why I did it, and (4) self-positioning in the world. Only the last theme evolved over the time period considered. Suicide notes shed light on the psychological state of the majority of young note leavers and suggest the persistent feelings of distress and entrapment before the suicide, which may be important factors for caregivers and family members to monitor.

[When hotlines remain cold: Psychological support in the time of pandemic]

En Suisse, comme ailleurs dans le monde, de nombreuses hotlines pour le soutien psychologique à la population ont vu le jour durant la phase aiguë de la pandémie de COVID-19. Les professionnels en charge, généralement des spécialistes de l’aide psychologique d’urgence, étaient aux prises avec une situation inédite, différente des catastrophes pour lesquelles ils se préparent habituellement. La pandémie et les mesures de distanciation menaçant potentiellement la cohésion sociale, ils ont cherché, avec les hotlines, à réintroduire une forme de proximité, en soignant et cultivant le lien. La situation de pression et d’urgence, les inquiétudes des autorités et de la population, ainsi que les attentes politiques et sociétales, ont favorisé le développement de ces structures. Des facteurs, comme le besoin d’être utile et d’occuper une place ou celui d’agir pour maîtriser les mouvements d’angoisse suscités par une situation inconnue et inquiétante, ont certainement aussi joué un rôle chez les professionnels impliqués. Dans l’ensemble cependant, ces hotlines n’ont été que peu sollicitées, et leur utilité peut poser question. Cela renvoie à d’autres domaines où ont pu naître de nombreuses nouvelles offres, pas toujours en adéquation avec les besoins identifiés, alors même que beaucoup de structures existantes étaient parallèlement sous-employées, en particulier dans le domaine sanitaire. Ces constats plaident pour la nécessité d’éviter les réponses dans l’urgence lors de situations de crise et de penser les dispositifs à mettre en place plutôt que de les agir.

Esophageal perforation in eosinophilic esophagitis: five cases in children

Background and study aims  Eosinophilic esophagitis (EoE) is a chronic immune disease with increasing incidence. It is clinically defined by symptoms of esophageal dysfunction and histologically by eosinophilic polynuclear cell infiltration of the esophageal mucosa. Symptoms are not specific and include gastroesophageal reflux disease (GERD), dysphagia, vomiting or dietary blockages. Chronic inflammation of the mucosa may lead to narrowing of the esophageal lumen responsible for impactions. Extraction procedures can be complicated by dissection and perforation. Rare spontaneous ruptures of the esophagus known as Boerhaave syndrome are also possible. We report five cases of esophageal perforation in children with EoE, three with spontaneous rupture and two after an endoscopic procedure. The evolution was favorable under medical treatment.

Prevalence of somatic and psychiatric morbidity across occupations in Switzerland and its correlation with suicide mortality: results from the Swiss National Cohort (1990-2014)

BACKGROUND

Suicide is a major and complex public health problem. In Switzerland, suicide accounts for about 1000 deaths yearly and is the fourth leading cause of mortality. The first nationwide Swiss study of suicides identified eight male and four female occupations with statistically significant excess of suicide compared to the general Swiss population. Working time, self-employer status, low socio-economic status and low skill level required for occupation were associated with increase in suicide risk. Presently, we aim to compare the distribution of suicide risk across occupations with the prevalence of somatic and psychiatric morbidity in Swiss working-aged adults. We hypothesized that some diseases would cluster in particular occupations, indicating potential work-relatedness of suicides found in these occupations.

METHODS

We used the Swiss National Cohort (SNC) and included 10575 males and 2756 females deceased by suicide between 1990 and 2014. We estimated the prevalence of 16 categories of concomitant diseases in each occupation, using national mortality records, and assessed the homogeneity of diseases distribution across occupations. For diseases, which prevalence varied significantly across occupations, we analyzed the correlation with the distribution of suicide risk, estimated as the standardized mortality ratio (SMR) of suicide.

RESULTS

Mental and behavioral disorders were the most commonly reported concomitant diseases in our population. In men, the prevalence of these disorders and more specifically, the prevalence of substance-related and addictive disorders, and of psychotic disorders varied significantly across occupations and was correlated with the SMR of suicide. The prevalence of malignant neoplasms and the prevalence of diseases of the musculoskeletal system and connective tissue also varied significantly across male occupations, while in women, such a variation was observed for neoplasms of uncertain or unknown behavior and diseases of the nervous system and sense organs, without being correlated with the SMR of suicide.

CONCLUSION

Some of the identified morbidities can be occupation-related and could negatively affect the working capacity and the employability, which in turn could be related to the suicide. Disentangling concomitant diseases according to their work-relatedness and relationship with the suicide risk is important for identifying occupation-related suicides, understanding their characteristics, and developing appropriated interventions for their prevention.

Bronchopulmonary and vascular anomalies are frequent in children with oesophageal atresia

AIM

Oesophageal atresia is frequently associated with other malformations, and our aim was to use computed tomography (CT) to explore intrathoracic malformations in patients with this condition.

METHOD

This was retrospective study of children aged 0-16 with oesophageal atresia who were born in 1996-2013 and followed up at the French reference centre for rare oesophageal diseases at the University of Lille. Computed tomography scans were available for 48 of the 234 patients during follow-up visits, and these were reviewed by a thoracic radiologist.

RESULTS

More than two-thirds of the scans were performed to explore persistent respiratory symptoms. We found that six patients had a pulmonary malformations: four lobar agenesis, one right pulmonary aplasia and one congenital cystic adenomatoid malformation. Computed tomography enabled us to diagnose unexpected thoracic malformations in 16 patients: four lobar agenesis, six arteria lusoria, five persistent left superior vena cava and one partial anomalous pulmonary venous return. It also confirmed the diagnoses of suspected malformations in five patients: one congenital cystic adenomatoid malformation, one pulmonary hypoplasia, two right-sided aortic arches and one communicating bronchopulmonary foregut malformation.

CONCLUSION

Intrathoracic anomalies were frequently associated with oesophageal atresia, and contrast-enhanced chest CT scans should be performed on patients with persistent respiratory symptoms.

Natural History of Perianal Fistulising Lesions in Patients With Elderly-onset Crohn's Disease: A Population-based Study

INTRODUCTION

Most studies of elderly-onset Crohn's disease [CD; diagnosed in patients aged 60 or over] have described a mild course. However, data on the natural history of perianal fistulising CD [pfCD] in this population are scarce. In a population-based cohort study, we described the prevalence, natural history, and treatment of pfCD in patients with elderly-onset CD vs patients with paediatric-onset CD.

METHOD

All patients diagnosed with CD at or after the age of 60 between 1988 and 2006, were included [n = 372]. Logistic regression, Cox models, and a nested case-control method were used to identify factors associated with pfCD.

RESULTS

A total of 34 elderly patients [9% of the 372] had pfCD at diagnosis. After a median follow-up of 6 years (interquartile range [IQR]: 3; 10), 59 patients [16%] had pfCD; the same prevalence [16%] was observed in paediatric-onset patients. At last follow-up, anal incontinence was more frequent in elderly patients with pfCD than in elderly patients without pfCD [22% vs 4%, respectively; p < 10-4]. Rectal CD at diagnosis was associated with pfCD: hazard ratio (95% confidence interval [CI] = 2.8 [1.6-5.0]). Although 37% of the patients received immunosuppressants and 17% received anti-tumour necrosis factor agents, 24% [14 out of 59] had a definitive stoma at last follow-up.

CONCLUSION

During the first 6 years of disease, the prevalence of pfCD was similar in elderly and paediatric patients. Rectal involvement was associated with the appearance of pfCD in elderly-onset patients. Around a quarter of patients with elderly-onset CD will have a stoma. Our results suggest that treatment with biologics should be evaluated in these patients.

[Psychiatry in the time of pandemic : forging new ways without getting lost]

Coronavirus pandemic challenges mental health care providers in different ways. At an individual level, they have to adapt their clinical practice and consider specific issues of teleconsultations to address patient's needs. At a population level, dedicated interventions (e.g. hotlines, health professionals' support) have to strike a balance between « pathologizing » people's reactions and trivializing the psychological effects of a pandemic. Finally, psychiatric leaders must be able to advise decision-makers on mental-health policy and communication.

Differences and similarities in instant countertransference towards patients with suicidal ideation and personality disorders

BACKGROUND

Previous findings showed that suicidal patients elicit mostly negative countertransference such as distress, hopelessness, feelings of inadequacy, and apprehension, and that a concurrent personality disorder is associated with more feelings of entrapment and mistreatment, among other adverse reactions. No studies were however conducted on instant countertransference (iCT), i.e., after a single encounter, for example in an emergency setting. We aimed to evaluate the impact of suicidal ideations, self-harm and presence of personality disorders on instant Countertransference (iCT).

METHODS

Caregivers rated their iCT with two validated and standardized questionnaires after a first emergency or outpatient consultation. Suicidal ideation, self-harm and personality disorders were tested as predictors for iCT in a multivariate and multilevel analysis.

RESULTS

Thirty caregivers rated their iCT towards 321 patients. Personality disorders and suicidal ideation, but neither recent nor past history of self-harm, predicted iCT. Common iCT included tension, lack of self-confidence and feeling of being tied. iCT specifically associated with suicidal ideation included distress, lack of hope, confusion, and sense that the patient's life had little worth. In contrast, iCT towards patients with personality disorders suggested tension in the therapeutic relationship (low affiliation with patient, anger, disappointment, devaluation).

LIMITATIONS

Caregiver's characteristics were not considered in the analysis. Furthermore, while countertransference also includes unconscious phenomena, only conscious iCT was assessed.

CONCLUSIONS

Patients with suicidal ideation and personality disorders elicit common but also specific negative iCT. Mental health institutions need to devote specific resources (such as clinical supervision and training) to help caregivers manage their iCT.

[Sentinel program: Example of suicide prevention for an agricultural population in Switzerland]

OBJECTIVES

In the field of suicide prevention, the identification of risk groups is important, as is the training of front-line workers, to raise awareness of suicide issues. Agricultural workers represent a group at high risk of suicidal behavior due to various factors (low income of farmers, work related to climatic conditions, social isolation, poor access to primary care). The main objective of this article is to present the implementation of prevention training in suicide prevention for a population of agricultural workers in two cantons of French-speaking Switzerland (Vaud and Neuchâtel) which represent a population of about 980,000 inhabitants. The second objective is to identify the experiences of the participants in this training and their expectations.

METHODS

Suicide prevention training sessions are organized in collaboration with public health departments, agriculture departments and suicide prevention professionals. Each session is led by four trainers experienced in suicide prevention and belonging to the "Groupement Romand Prévention du Suicide" (GRPS) which manages the training and other training modules on this topic in French-speaking Switzerland. The GRPS guarantees the content of the training as well as the updating of scientific knowledge. The training model is based on a concept that alternates between brief theoretical contributions, exchanges between participants in plenary sessions and role playing in small groups. The training has two main objectives: on the one hand to work on the participants' representations of suicide and to modify their posture by training "sentinels", i.e. "peers" who can establish a link between suffering individuals and the available support resources. On the other hand, to give key messages: dare to talk about the suicidal question and to not remain alone with this.

RESULTS

Between December 2016 and May 2018, nine sessions were held in the two cantons of Vaud and Neuchâtel with a total of 220 participants. The sessions took place in agricultural schools or buildings related to agriculture. Invited to express themselves on the theme of suicide as well as on the concept of training, agricultural workers all verbalized the importance of this issue and were often very moved when the subject was discussed. The topics addressed by the participants were the taboo aspect of the subject, the difficulty of talking about it and the need to be able to address the subject (breaking the isolation). Participants also highlighted the need for peers to act as relays for help.

CONCLUSIONS

The sessions were highly appreciated by the organizers concerned, particularly by the public health and agricultural departments. Participants expressed their satisfaction at the opportunity to express their views on this subject, regretting that such initiatives are all too rare. Although studies highlight the difficulty of emotional expression in the agricultural field, we observed on the contrary a great facility of the participants to express their emotions in relation to the suicidal theme. We have highlighted that the issue of suicide in this population is linked to several causal factors, as is the suicidal issue more broadly. Factors specific to this population emerged from the sessions, including working conditions and difficulties related to the family environment of farmers. There is a need to strengthen suicide prevention with training programs among the agricultural population. We also note the major importance of improving access to mental health care which is often very deficient in rural areas.

Suicides in Psychiatric Patients: Identifying Health Care-Related Factors through Clinical Practice Reviews

The objective of this study was to identify health care-related factors associated with death by suicide in psychiatric patients and to gain insight into clinician views on how to deal with suicidality. The study material derived from a clinician committee in a psychiatric department reviewing every outpatient and inpatient suicide in a standardized way. Reports' conclusions and corresponding plenary discussion minutes regarding 94 suicides were analyzed using inductive thematic content analysis. Health care-related factors were categorized into 4 themes: patient evaluation, patient management, clinician training, and involvement of relevant non-clinical partners. Clinician views on the themes were expressed through statements (i) promoting or restricting an aspect of care (here called recommendations), which mainly followed existing guidelines and were consensual and (ii) without precise indication (here called comments), which departed from mainstream opinions or addressed topics not covered by existing policy. Involvement of non-clinical partners emerged as a new key issue for suicide prevention in psychiatric departments and should be openly discussed with patients. Clinicians preferred balanced conclusions when they reviewed suicide cases.

Physical activity is associated with improved bone health in children with inflammatory bowel disease

BACKGROUND & AIMS

Bone health is an important concern in patients with inflammatory bowel disease (IBD). Low bone mineral density (BMD) is a powerful predictor of fracture risk in IBD patients. Physical activity (PA) plays an important role in bone health. However, PA data for children and adolescents with IBD are scarce. The primary aim is to evaluate the relationship between PA and BMD in children with IBD. The secondary aim was to assess the relationship between PA and quality of life.

METHODS

Eighty-four IBD paediatric patients (45 boys) aged 14.3 ± 2.7 years were included (disease activity: (i) remission, n = 62; (ii) mild, n = 18; (iii) severe disease, n = 1). BMD was measured using dual-energy X-ray absorptiometry and expressed as age- and sex-based Z-scores. Each patient wore a triaxial accelerometer for seven consecutive days for objective PA quantification. Quality of life was assessed using the PedsQL™ and energy intake was assessed prospectively for three days using a dietary diary.

RESULTS

BMD Z-score was -0.96 ± 1.11. Only five patients (6%) fulfilled the recommendation of 60 min of daily moderate-to-vigorous PA (MVPA). The proportion of children with osteopenia and osteoporosis was 51% and 4%, respectively. After adjustment for confounders (pubertal status and body mass index), total PA and time in MVPA were positively associated with BMD (regression coefficient per one standard deviation increase in PA parameters = 0.26; P < 0.05). There was no association between time spent in MVPA and total PA, and total quality of life score.

CONCLUSIONS

PA likely is associated with improved bone health in IBD children. Intervention studies investigating a causal relationship between PA and BMD in paediatric patients with IBD are warranted.

[Meeting suicidal patient : ongoing actions in French speaking Switzerland]

This article describes a model designed by an ad hoc group in French-speaking Switzerland to help professionals meeting suicidal patients. Based on current scientific knowledge, it promotes the clinical encounter with patient rather than a quantitative risk assessment, which may interfere with therapeutic alliance. This model underlines the importance of a reflexive position from the caregiver, who should keep a critical view on his own practice and opinions on suicidal process.

The implementation and first insights of the French-speaking Swiss programme for monitoring self-harm

AIMS OF THE STUDY

Self-harm is a major risk factor for suicide but remains poorly documented. No data on self-harm in French-speaking Switzerland exist. To address this deficiency, the Swiss Federal Office of Public Health commissioned a specific self-harm monitoring programme. We present and discuss its implementation and first findings.

METHODS

Every patient aged 18&ndash;65 years presenting for self-harm to the emergency departments of the Lausanne and Neuch&acirc;tel general hospitals were included in the monitoring programme over a 10-month period (December 2016 to September 2017). Clinicians collected anonymous sociodemographic and clinical data.

RESULTS

The sample included 490 patients (54.9% female and 45.1% male) for 554 episodes of self-harm, showing a higher proportion of patients aged 18&ndash;34 (49.2%) than older age groups (35&ndash;49, 33.7% and 50&ndash;65, 17.1%). Patients were mostly single (56.1%) and in problematic socioeconomic situations (65.7%). Self-poisoning was the most commonly used method (58.2%) and was preferred by women (71% of females and 42.5% of males, Fisher&rsquo;s exact test, p &lt;0.001) and the majority of patients (53.3%) had experienced at least one previous episode of self-harm. The self-harm rate was 220 per 100,000 inhabitants in Lausanne and 140 in Neuch&acirc;tel. Suicidal intent was clear for 50.6% of the overall sample, unclear for 25.1% and absent for 24.3%. It differed significantly between sites (&chi;2(2) = 9.068, p = 0.011) as Lausanne reported more incidents of unclear intent (27.7% versus 17.4% in Neuch&acirc;tel) and Neuch&acirc;tel more incidents with absence of intent (33.1% versus 21.3% in Lausanne). In Lausanne, patients more frequently resorted to methods such as jumping from a height (11.4%) and hanging (9%) than in Neuch&acirc;tel (1.6% and 4.9%, Fisher&rsquo;s exact test, p = 0.006).

CONCLUSIONS

Our results are globally consistent with previous research on self-harm. We found significant inter-site differences in methods, suicidal intent and self-harm rates. Our findings highlight the importance of implementing local self-harm monitoring to identify specific at-risk groups and develop targeted preventive intervention.

Screening of esophageal varices in children using esophageal capsule endoscopy: a multicenter prospective study

BACKGROUND

Esophagogastroduodenoscopy (EGD) is the standard method for diagnosis of esophageal and gastric varices in children. In this prospective study we evaluated the use of PillCam esophageal capsule endoscopy (ECE) in pediatric patients.

METHODS

Patients aged 7 to 18 years presenting with portal hypertension and/or cirrhosis underwent ECE (PillCam ESO 2, Given Imaging Ltd.) followed by EGD.

RESULTS

102 patients were screened, 81 (52 boys; mean age 13.96 ± 0.25 years) were included and 21 were excluded (16 for "candy test" failure). Esophageal varices were identified by EGD in 62 patients (77 %) and by ECE in 57 patients (70 %) using the de Franchis classification (DFC). The sensitivity of ECE for esophageal varices was 92 % and the specificity was 100 % using DFC. Based upon 57/81 patients with small, medium, and large varices on both ECE and EGD, using DFC, the sensitivity, specificity, positive (PPV) and negative predictive value (NPV) were 55 %, 92 %, 89 %, and 63 %, respectively, giving a total overall accuracy of 72 %. To improve sensitivity and specificity in classification of esophageal varices, we propose using a modified score. This score detected esophageal varices with 100 % sensitivity, 93 % specificity, 94 % PPV, and 100 % NPV, giving a total overall accuracy of 97 %. All patients preferred ECE over EGD. No capsule retention was recorded.

CONCLUSIONS

ECE is a well-tolerated and safe procedure in children. Using the modified score, the sensitivity of ECE is currently sufficient to detect esophageal varices and replace EGD in infants with suspicion of esophageal varices or when EGD is refused.

Circumferential Esophageal Replacement by a Tissue-engineered Substitute Using Mesenchymal Stem Cells: An Experimental Study in Mini Pigs

Tissue engineering appears promising as an alternative technique for esophageal replacement. Mesenchymal stem cells (MSCs) could be of interest for esophageal regeneration. Evaluation of the ability of an acellular matrix seeded with autologous MSCs to promote tissue remodeling toward an esophageal phenotype after circumferential replacement of the esophagus in a mini pig model. A 3 cm long circumferential replacement of the abdominal esophagus was performed with an MSC-seeded matrix (MSC group, n = 10) versus a matrix alone (control group, n = 10), which has previously been matured into the great omentum. The graft area was covered with an esophageal removable stent. A comparative histological analysis of the graft area after animals were euthanized sequentially is the primary outcome of the study. Histological findings after maturation, overall animal survival, and postoperative morbidity were also compared between groups. At postoperative day 45 (POD 45), a mature squamous epithelium covering the entire surface of the graft area was observed in all the MSC group specimens but in none of the control group before POD 95. Starting at POD 45, desmin positive cells were seen in the graft area in the MSC group but never in the control group. There were no differences between groups in the incidence of surgical complications and postoperative death. In this model, MSCs accelerate the mature re-epitheliazation and early initiation of muscle cell colonization. Further studies will focus on the use of cell tracking tools in order to analyze the becoming of these cells and the mechanisms involved in this tissue regeneration.

Influence of Percutaneous Endoscopic Gastrostomy on Gastroesophageal Reflux Disease in Children

OBJECTIVE

To determine if gastroesophageal reflux disease (GERD) is present at long-term follow-up after percutaneous endoscopic gastrostomy (PEG), and to identify factors associated with the occurrence or aggravation of GERD after PEG placement.

STUDY DESIGN

This prospective, observational study was conducted in our single tertiary center over a 13-year period (gastrostomy performed from 1990 to 2003 and follow-up to 2015). Every child who underwent PEG in our center (N = 368) from 1990 to 2003 was eligible. GERD was defined by clinical manifestations requiring antisecretory or prokinetic treatment, occurrence of a GERD-related complication, or the need for antireflux surgery. Outcomes among patients without antireflux surgery were also assessed. Multivariate analysis was used to identify factors aggravating GERD after PEG placement.

RESULTS

A total 326 patients (89%; 56% with a neurologic impairment) were studied with a median follow-up after 3.5 years (range, 2.0-13.5 years). After PEG placement, GERD appeared in 11% of patients and was aggravated in 25% of patients with preexisting GERD. Factors associated with GERD worsening after PEG placement were neurologic impairment and preexisting GERD. Only 53 patients (16%) required antireflux surgery, among whom 22 required surgery in the year after PEG. Neurologic impairment was the only factor significantly associated with the need for antireflux surgery.

CONCLUSIONS

GERD predominantly remains clinically controlled after PEG placement. Routine antireflux surgery at the time of PEG placement is not justified.

Dramatic Increase in Incidence of Ulcerative Colitis and Crohn's Disease (1988-2011): A Population-Based Study of French Adolescents

OBJECTIVES

Few data are available to describe the changes in incidence of pediatric-onset inflammatory bowel disease (IBD). The aim of this study was to describe changes in incidence and phenotypic presentation of pediatric-onset IBD in northern France during a 24-year period.

METHODS

Pediatric-onset IBD (<17 years) was issued from a population-based IBD study in France between 1988 and 2011. Age groups and digestive location were defined according to the Paris classification.

RESULTS

1,350 incident cases were recorded (8.3% of all IBD) including 990 Crohn's disease (CD), 326 ulcerative colitis (UC) and 34 IBD unclassified (IBDU). Median age at diagnosis was similar in CD (14.4 years (Q1=11.8-Q3=16.0)) and UC (14.0 years (11.0-16.0)) and did not change over time. There were significantly more males with CD (females/males=0.82) than UC (females/males=1.25) (P=0.0042). Median time between onset of symptoms and IBD diagnosis was consistently 3 months (1-6). Mean incidence was 4.4/10⁵ for IBD overall (3.2 for CD, 1.1 for UC and 0.1 for IBDU). From 1988-1990 to 2009-2011, a dramatic increase in incidences of both CD and UC were observed in adolescents (10-16 years): for CD from 4.2 to 9.5/10⁵ (+126%; P<0.001) and for UC, from 1.6 to 4.1/10⁵ (+156%; P<0.001). No modification in age or location at diagnosis was observed in either CD or UC.

CONCLUSIONS

In this population-based study, CD and UC incidences increased dramatically in adolescents across a 24-year span, suggesting that one or more strong environmental factors may predispose this population to IBD.

Prokaryotic assemblages in the maritime Antarctic Lake Limnopolar (Byers Peninsula, South Shetland Islands)

The potentially metabolically active components within the prokaryotic assemblages inhabiting the Antarctic Lake Limnopolar (Byers Peninsula, Maritime Antarctica) were investigated by a polyphasic approach which included culture-dependent and culture-independent methods (based on RNA molecules). Results support previous observations on the Proteobacteria and Bacteroidetes dominance, followed by Actinobacteria, in Antarctic lakes. In particular, Alpha-, Betaproteobacteria and Bacteroidetes were mainly detected by CARD-FISH and cDNA cloning, whereas Gammaproteobacteria and Actinobacteria dominated within the cultivable fraction. Overall, this study demonstrates the survival potential and physiological heterogeneity of the prokaryotic community in the Lake Limnopolar. The microbial community composition in the lake is affected by external influences (such as marine environment by sea spray and seabird dropping, and microbial mats and mosses of the catchment). However, most external bacteria would be inactive, whereas typical polar taxa dominate the potentially active fraction and are subsidized by external nutrient sources, thus assuming the main biogeochemical roles within the lake.

Extra-intestinal Manifestations at Diagnosis in Paediatric- and Elderly-onset Ulcerative Colitis are Associated With a More Severe Disease Outcome: A Population-based Study

BACKGROUND AND AIMS

Data on extra-intestinal manifestations [EIM] and their impact on the disease course of ulcerative colitis [UC] in population-based cohorts are scarce, particularly in paediatric- and elderly-onset UC patients. The aims of this population-based study were to assess: 1] the occurrence of EIM in paediatric- and elderly-onset UC; 2] the factors associated with EIM; and 3] their impact on long-term disease outcome.

METHODS

Paediatric-onset [< 17 years at diagnosis] and elderly-onset UC patients [> 60 years at diagnosis] from a French prospective population-based registry [EPIMAD] were included. Data on EIM and other clinical factors at diagnosis and at maximal follow-up were collected.

RESULTS

In all, 158 paediatric- and 470 elderly-onset patients were included [median age at diagnosis 14.5 and 68.8 years, median follow-up 11.2 and 6.2 years, respectively]. EIM occurred in 8.9% of childhood- and 3% of elderly-onset patients at diagnosis and in 16.7% and 2.2% of individuals during follow-up [p < 0.01], respectively. The most frequent EIM was joint involvement [15.8% of paediatric onset and 2.6% of elderly-onset]. Presence of EIM at diagnosis was associated with more severe disease course [need for immunosuppressants or biologic therapy or colectomy] in both paediatric- and elderly-onset UC (hazard ratio [HR] = 2.0, 95% confidence interval [CI]: 1.0-4.2; and HR = 2.8, 0.9-7.9, respectively). Extensive colitis was another independent risk factor in both age groups.

CONCLUSIONS

Elderly-onset UC patients had lower risk of EIM either at diagnosis or during follow-up than paediatric-onset individuals. EIM at diagnosis predicted more severe disease outcome, including need for immunosuppressive or biologic therapy or surgery, in both paediatric- and elderly-onset UC.

Molecular imaging for prostate cancer: Performance analysis of 68Ga-PSMA PET/CT versus choline PET/CT

INTRODUCTION

There is a need for a precise and reliable imaging to improve the management of prostate cancer. In recent years the PET/CT with choline has changed the handling of prostate cancer in Europe, and it is commonly used for initial stratification or for the diagnosis of a biochemical recurrence, although it does not lack limitations. Other markers are being tested, including the ligand of prostate-specific membrane antigen (PSMA), that seems to offer encouraging prospects. The goal of this piece of work was to critically review the role of choline and PSMA PET/CT in prostate cancer.

EVIDENCE ACQUISITION

A systematic literature review of databases PUBMED/MEDLINE and EMBASE was conducted searching for articles fully published in English on the PET marker in prostate cancer and its clinical application.

EVIDENCE SYNTHESIS AND DISCUSSION

It seems as 68Ga-PSMA PET/CT is better than PET/CT in prostate cancer to detect primary prostate lesions, initial metastases in the lymph nodes and recurrence. However, further research is required to obtain high-level tests. Also, other PET markers are studied. Moreover, the emergence of a new PET/MR camera could change the performance of PET imaging.