[Questionnaire on Treatment Satisfaction in Inpatient Child and Adolescent Psychiatry (FBZ-KJP) - Results of a Swiss Pilot Study]

Questionnaire on Treatment Satisfaction in Inpatient Child and Adolescent Psychiatry (FBZ-KJP) - Results of a Swiss Pilot Study Abstract: Objectives: Patient satisfaction is an established indicator for medical interventions. Existing questionnaires for the assessment of patient satisfaction in child and adolescent psychiatry are too global to target quality improvement in child and adolescent psychiatric hospitals. The assessment of patient satisfaction in child and adolescent psychiatry is very challenging because specific demands (development status, role of parents in treatment) have been taken into account. Therefore, an expert team leaded by the Swiss Society of Child and Adolescent Psychiatry developed a targeted instrument to assess patient satisfaction in both language regions (i. e., German and French). Methods: The article reviews the development of a new child and adolescent psychiatric questionnaire for the assessment of patient satisfaction as well as the findings of a survey conducted in a representative sample of 174 patients and 145 parents in six hospitals. Results: The internal consistency (Cronbach's α = .93) is excellent. The questionnaire has high levels of both convergence and face validity, and the correlation with the Client Satisfaction Questionnaire (CSQ-8) is ρ = .80 (patient-report) and .83 (parent-report). Furthermore, this questionnaire reveals the relative strengths and weaknesses of individual hospitals. The correlation between patient and parent assessment is, as expected, moderate (ρ = .29, for the total score and ρ = .39 for the CSQ-8). Conclusions: The Patient Satisfaction Questionnaire can be recommended to professionals as a standard for collecting data on client satisfaction within child and adolescent psychiatry.

Evolution of Clinical Outcome During Adolescents’ Psychiatric Inpatient Care: A Prospective Multiple Informant Study

Background:

Examining the effectiveness and adequacy of adolescents’ psychiatric inpatient treatment through multiple perspectives is crucial to provide the best care.

Objectives:

The aims of the current study were to examine the consistencies and discrepancies between patients and clinicians and to understand how each group considered the timing of improvement of symptoms and psychosocial difficulties of adolescents during a psychiatric inpatient stay.

Methods:

The Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA, assessing symptoms and psychosocial difficulties) was rated on a weekly basis by patients and clinicians during a psychiatric inpatient stay. Data were collected from 297 patients, 58.2% females.

Results:

Both clinicians and patients reported a significant decrease of the HoNOSCA scores from admission to discharge, revealing that inpatient treatment is perceived as helping the adolescents to alleviate their symptoms and psychosocial difficulties. However, the item-by-item analyses indicated that patients and clinicians reported difficulties in different symptoms and psychosocial domains. Moreover, the week-by-week analyses revealed discrepancies in the perception of the time-course of clinical outcome- changes between clinicians and patients, as well as between males and females, and between voluntarily and involuntarily admitted patients.

Conclusions:

By integrating perspectives of patients and clinicians and their respective timelines, as well as by taking into account the mode of admission and the patient’s gender, this study provides a deeper understanding of the evolution of clinical outcome during adolescents’ hospitalizations, which allows to adapt their treatment and therewith, to help patients more efficiently.

Pneumococcal vaccination in lung transplant patients

Introduction: This review analyzes the efficacy of pneumococcal vaccinations in lung transplant patients before and after transplantation.Areas covered: This review addresses the risk for respiratory infections, in particular pneumococcal infections, in lung transplantation patients in the context of immunodeficiency and immunosuppressive medication. Vaccination is recommended to counteract the increased risk of pneumococcal infection, and the relevant guidelines are discussed in this review. The design of specific vaccination schedules is required because of the impaired antibody response in specific patient categories.Expert opinion: Lung transplantation candidates should be vaccinated with pneumococcal vaccines prior to transplantation. Currently, the 23-valent pneumococcal polysaccharide vaccine offers the broadest coverage, but the antibody response should be monitored. New generation pneumococcal conjugate vaccines with equally broad serotype coverage could be used in the future. During the post-transplantation period, the immune status of the patients should be monitored regularly, and vaccination should be repeated when indicated.

Lipid Disturbances in Adolescents Treated With Second-Generation Antipsychotics: Clinical Determinants of Plasma Lipid Worsening and New-Onset Hypercholesterolemia

OBJECTIVE

Lipid disturbances following treatment with second-generation antipsychotics (SGAs) represent a major health concern. A previous study determined that early changes of plasma lipid levels ≥ 5% during the first month of treatment with SGAs predicts further lipid worsening and development of dyslipidemia. This current study aimed to determine the proportion of adolescents with early lipid changes ≥ 5% and who develop dyslipidemia during SGA treatment.

METHODS

Data were obtained from a 1-year longitudinal study ongoing since 2007 including 53 adolescent psychiatric (ICD-10) patients (median age 16.5 years; interquartile range [IQR], 14.8-17.5 years) whose metabolic parameters were monitored prospectively during treatment. Plasma lipid levels (total, low-density lipoprotein, high-density lipoprotein [HDL-C], and non-high-density lipoprotein cholesterol and fasting triglycerides ) were measured at baseline and after 1, 3, and/or 12 months of SGA treatment.

RESULTS

Half (n = 26; 49%) the adolescents had an early increase of total cholesterol levels by 5% or more during the first month of treatment, and one-third (n = 8/24; 33%) developed new-onset hypercholesterolemia during the first year of treatment. Hypercholesterolemia developed more frequently in female patients (P = .01) and in patients with an early increase of total cholesterol ≥ 5% (P = .02). Finally, patients whose HDL-C levels decreased by ≥ 5% during the first month of treatment had a larger HDL-C worsening after 3 months of treatment as compared with patients with early decrease of HDL-C by < 5% (P = .02).

CONCLUSIONS

This study underlines the importance of prospectively monitoring metabolic parameters in adolescents after the introduction of SGAs.

Clinical significance of assertive community treatment among adolescents

PURPOSE

The efficacy of assertive community treatment for children and adolescents is proven in the United States, but remains controversial in Europe. Moreover, most studies showing positive outcomes of assertive community treatment are limited to statistically significant differences and do not consider whether the treatment is also subjectively clinically meaningful for the patient. Using a naturalistic sample, the present study aims to assess statistical and clinical significance of an assertive community treatment unit for adolescents in Europe.

METHODS

Linear mixed-effects models and reliable change indices were used to respectively assess the statistical and clinical significance of assertive community treatment in 179 adolescents (mean age = 15.76, SD = 1.76) with severe mental illnesses.

RESULTS

Difficulties related to mental health (measured by the Health of the Nation Outcome Scales for Children and Adolescents, HoNOSCA) and overall functioning (measured by the Global Assessment of Functioning scale) statistically improved (all ps < 0.001) from admission to discharge. Additionally, a considerable proportion of patients (from 14% to 21%) clinically recovered to functional levels.

CONCLUSION

Our results support the fact that assertive community treatment can have convincing and positive clinical outcomes in European settings.

Second-Generation Antipsychotics in Adolescent Psychiatric Patients: Metabolic Effects and Impact of an Early Weight Change to Predict Longer Term Weight Gain

OBJECTIVES

To examine the metabolic profile of adolescents at baseline and to determine the potential predictive power of a 1-month weight gain (WG) on weight changes during longer term second-generation antipsychotic (SGA) treatment.

METHODS

A retrospective chart review study, including patients between 13 and 18 years of age and treated with SGA, was conducted. Available data at baseline, 1, 3, and 12 months of treatment were recorded.

RESULTS

Four hundred fifty-six patients were included, with a median age of 15 years. Ten percent of the patients were obese (>95th percentile) and abdominal obesity (>90th percentile) was observed in 12% of patients. In a subgroup of 42 patients with both baseline, 1, and 3-month weight data available, WG >4.5% after 1 month was found to be the best predictor (sensitivity: 100; specificity: 66; area under the curve: 83) for a WG >15% after 3 months. After adjusting for potential confounders, a threshold of WG >4% was found as being the best predictor.

CONCLUSIONS

A worrisome prevalence of metabolic disorders was observed in an adolescent psychiatric cohort. In such patients, a WG >4% during the first month of treatment should raise concerns about weight controlling strategies. Further research is needed to confirm the present results and to determine the impact of a 1-month WG on a 1-year weight change.

Psychotropic Drug Prescription in Adolescents: A Retrospective Study in a Swiss Psychiatric University Hospital

OBJECTIVES

This retrospective study aims to evaluate off-label prescriptions and administrations of psychotropic medications in adolescents in a university psychiatric hospital in Switzerland.

METHODS

Data were collected during the entire stays from the electronic database for 76 inpatients in 2008 and 76 inpatients in 2014. Data collected included gender, age, psychiatric diagnosis, duration of hospitalization, and psychotropic drug prescriptions and administrations.

RESULTS

A total of 224 psychotropic drugs (mean 2.9 drugs/patient) were prescribed in 2008 and 268 (mean 3.5 drugs/patient) in 2014. Due to the prescriptions of some drugs as required, only 76% of the prescriptions were actually administered in 2008 (mean 2.3 drugs/patient) and 55% in 2014 (mean 1.9 drugs/patient). Antipsychotics were the most frequently prescribed drugs in 2008 (74% of patients) and 2014 (86% of patients). Anxiolytics were also highly prescribed in 2008 (54% of patients) and 2014 (66% of patients), as well as antidepressants in 2008 (30% of patients), but less in 2014 (13% of patients). Overall, 69% of prescriptions were found to be off label in 2008 and 68% in 2014, according to age, diagnosis, dose, or formulation as approved by Swissmedic. The medication classes with the highest rate of off-label prescriptions were antidepressants (100% for both years), antipsychotics (94% in 2008 and 92% in 2014), and hypnotics (67% in 2008 and 100% in 2014). For both study periods, at least one off-label psychotropic drug prescription and administration was recorded in 96% and 79% of the patients, respectively.

CONCLUSION

The high rate of off-label psychotropic drug use strengthens the need for clinical trials to better evaluate the efficacy and safety of these treatments in adolescents.

[Novelties 2016 in pediatrics]

Nutrition is central in pediatric care : essential for growth and development, it plays also a role in the prevention of many diseases.Even if breastfeeding is highly recommended, its implementation may be difficult in particular for premature and ill newborns. The creation of a specific unit for breastfeeding support in neonatology allows to help mothers willing to nurse and to improve the rate of breastfeeding for these vulnerable infants.Eating disorders represent an important challenge for patient care. Early detection and rapid management of anorexia is essential for the prognosis. This article describes the challenges and the practical process underlying the development of a practical guideline to manage children and adolescents hospitalized for anorexia.

Can the Health of the Nation Outcome Scales for Children and Adolescents predict the necessity of inpatient stay during assertive community treatment?

Understanding the trajectories of youths within Child and Adolescents Mental Health Service (CAMHS) is of primary importance. Our objective is to assess the usefulness of the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) to predict inpatient (IP) stay for youths followed by assertive community treatment (ACT) teams. 82 youths followed exclusively by ACT and 42 who needed IP were assessed with the HoNOSCA at admission to the program. The HoNOSCA allowed the computing of three scores: a total score, an externalizing symptoms (Ext) score and an emotional problems (Emo) score. Logistic regressions revealed that the three HoNOSCA scores at admission of ACT predicted later need for hospitalization. Using ROC curve analyses, we set up cut off scores with appropriate sensitivity and specificity for the HoNOSCA Total and Ext to optimally predict the need for hospitalization. This study revealed that the HoNOSCA may be a useful tool to predict the need for later IP during ACT. Such knowledge is important to set up the best therapeutic strategies.

Patients' satisfaction with community treatment: a pilot cross-sectional survey adopting multiple perspectives

ACCESSIBLE SUMMARY

Patients' satisfaction is scarcely studied within the context of community treatment for adolescents. Thus, this study adopts a multiple perspective on patients' satisfaction (including service users as well as staff members). The results highlighted that all informants (patients, foster carers in foster homes and professional caregivers from community treatment teams) perceived the patients to be satisfied, with foster carers reporting the highest patient satisfaction rate. Considering the patient satisfaction rate from multiple perspectives provides complementary understandings. Clinical outcomes and, specifically, a reduction in emotional difficulties were related to patient's satisfaction, but only from the patients' perspective.

ABSTRACT

Community treatment (CT) teams in Switzerland provide care to patients who are unable to use regular child and adolescent mental health services (i.e. inpatient and outpatients facilities). No study has considered patients' self-rated satisfaction alongside with staff members' perspectives on patient satisfaction. Thus, adopting a cross-sectional survey design, we collected patients' satisfaction using the Client Satisfaction Questionnaire (CSQ-8), rated by multiple informants (patients, foster carers in foster homes and professional caregivers from CT teams). Professional caregivers assessed clinical outcomes using the Health of the Nation Outcome Scale for Children and Adolescents. The results indicated that all informants were satisfied with the community treatment teams. The satisfaction scores were not correlated across informants; however, the alleviation of emotional symptoms was correlated with patients' satisfaction. This study indicated that the use of a combined approach including the views of service users and professionals gives important complementary information. Finally, in our sample, lower emotional symptoms were linked to enhanced patient satisfaction. This study demonstrated the importance of considering multiple perspectives to obtain the most accurate picture of patients' satisfaction. Second, focusing on the reduction of emotional symptoms might lead to a higher degree of patients' satisfaction.

[Extension of mobile team services to the home: pilot project in the Vaud canton]

The main objective of this project about mobile team service extension to the socio-educational home of the whole Vaud canton targets to decompartmentalize the socio-educational and youth-psychiatry domains. 64 patient were assessed during this pilot phase (after one-year functioning). In addition, a satisfaction survey was done either at the end of the follow up or at the end of the pilot phase of the project (31.12.2012). This experience was very positive as highlighted by the vast majority of the person involved in the socio-educational and youth-psychiatric domains taking care of youth. A desire of extension of mobile team service to other institutional structure or other situations was expressed.

The French adaptation of the Health of the Nation Outcome Scale for Children and Adolescents Self-Rated Form (F-HoNOSCA-SR): validation and clinical routine use

The current study aimed to explore the validity of an adaptation into French of the self-rated form of the Health of the Nation Outcome Scales for Children and Adolescents (F-HoNOSCA-SR) and to test its usefulness in a clinical routine use. One hundred and twenty nine patients, admitted into two inpatient units, were asked to participate in the study. One hundred and seven patients filled out the F-HoNOSCA-SR (for a subsample (N=17): at two occasions, one week apart) and the strengths and difficulties questionnaire (SDQ). In addition, the clinician rated the clinician-rated form of the HoNOSCA (HoNOSCA-CR, N=82). The reliability (assessed with split-half coefficient, item response theory (IRT) models and intraclass correlations (ICC) between the two occasions) revealed that the F-HoNSOCA-SR provides reliable measures. The concurrent validity assessed by correlating the F-HoNOSCA-SR and the SDQ revealed a good convergent validity of the instrument. The relationship analyses between the F-HoNOSCA-SR and the HoNOSCA-CR revealed weak but significant correlations. The comparison between the F-HoNOSCA-SR and the HoNOSCA-CR with paired sample t-tests revealed a higher score for the self-rated version. The F-HoNSOCA-SR was reported to provide reliable measures. In addition, it allows us to measure complementary information when used together with the HoNOSCA-CR.

Influence of CRTC1 polymorphisms on body mass index and fat mass in psychiatric patients and the general adult population

IMPORTANCE

There is a high prevalence of obesity in psychiatric patients, possibly leading to metabolic complications and reducing life expectancy. The CREB-regulated transcription coactivator 1 (CRTC1) gene is involved in energy balance and obesity in animal models, but its role in human obesity is unknown.

OBJECTIVE

To determine whether polymorphisms within the CRTC1 gene are associated with adiposity markers in psychiatric patients and the general population.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective and prospective data analysis and population-based samples at Lausanne and Geneva university hospitals in Switzerland and a private clinic in Lausanne, Switzerland. The effect of 3 CRTC1 polymorphisms on body mass index (BMI) and/or fat mass was investigated in a discovery cohort of psychiatric outpatients taking weight gain-inducing psychotropic drugs (sample 1, n = 152). The CRTC1 variant that was significantly associated with BMI and survived Bonferroni corrections for multiple comparison was then replicated in 2 independent psychiatric samples (sample 2, n = 174 and sample 3, n = 118) and 2 white population-based samples (sample 4, n = 5338 and sample 5, n = 123,865).

INTERVENTION

Noninterventional studies.

MAIN OUTCOME AND MEASURE

Difference in BMI and/or fat mass between CRTC1 genotype groups.

RESULTS

Among the CRTC1 variants tested in the first psychiatric sample, only rs3746266A>G was associated with BMI (P(adjusted) = .003). In the 3 psychiatric samples, carriers of the rs3746266 G allele had a lower BMI than noncarriers (AA genotype) (sample 1, P = .001; sample 2, P = .05; and sample 3, P = .0003). In the combined analysis, excluding patients taking other weight gain-inducing drugs, G allele carriers (n = 98) had a 1.81-kg/m² lower BMI than noncarriers (n = 226; P < .0001). The strongest association was observed in women younger than 45 years, with a 3.87-kg/m² lower BMI in G allele carriers (n = 25) compared with noncarriers (n = 48; P < .0001), explaining 9% of BMI variance. In the population-based samples, the T allele of rs6510997C>T (a proxy of the rs3746266 G allele; r² = 0.7) was associated with lower BMI (sample 5, n = 123,865; P = .01) and fat mass (sample 4, n = 5338; P = .03). The strongest association with fat mass was observed in premenopausal women (n = 1192; P = .02).

CONCLUSIONS AND RELEVANCE

These findings suggest that CRTC1 contributes to the genetics of human obesity in psychiatric patients and the general population. Identification of high-risk subjects could contribute to a better individualization of the pharmacological treatment in psychiatry.

Treatment motivation in adolescents with psychosis or at high risk: determinants and impact on improvements in symptoms and cognitive functioning, preliminary results

Low motivation is frequent in chronic disorders such as psychosis and may limit treatment efficacy. Although some evidence supports this view in adults, few studies so far have focused on adolescents. We assessed the impact of baseline symptoms, cognitive deficits and cognitive treatment characteristics on treatment motivation (TM), and examined whether TM affected treatment outcome. Twenty-eight adolescents with psychotic disorders participated in 16 sessions of computerized cognitive remediation or games. TM was assessed for each session. Lower TM was predicted by more severe symptoms at baseline, and was associated with smaller improvements in symptoms and both cognitive and psychosocial functioning at the end of the intervention. Experiencing success in the treatment exercises enhanced TM in all patients.

Early tailored assertive community case management for hard-to-engage adolescents suffering from psychiatric disorders: an exploratory pilot study

AIM

The study aims to evaluate the effects of assertive community treatment (ACT) on the mental health and overall functioning of adolescents suffering from severe psychiatric disorders and who refuse any traditional child psychiatric care. There are a few studies evaluating the effects of ACT on a population of adolescents with psychiatric disorders. This short report highlights the impact of an ACT programme tailored to the needs of these patients, not only as an alternative to hospitalization, but also as a new form of intervention for patients that are difficult to engage.

METHODS

The effect of ACT on 35 adolescents using the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) as a measuring tool in pre- and post-intervention was evaluated.

RESULTS

The results show that the intervention was associated with a significant improvement on the HoNOSCA overall score, with the following items showing significant amelioration: hyperactivity/focus problems, non-organic somatic symptoms, emotional symptoms, scholastic/language skills, peer relationships, family relationships and school attendance.

CONCLUSION

ACT appears as a feasible intervention for hard-to-engage adolescents suffering from psychiatric disorders. The intervention seems to improve their mental health and functioning. This pilot study may serve as a basis to prepare a controlled study that will also take the costs of the intervention into account.

Computer-assisted cognitive remediation in adolescents with psychosis or at risk for psychosis: a 6-month follow-up

Urben S, Pihet S, Jaugey L, Halfon O, Holzer L. Computer-assisted cognitive remediation in adolescents with psychosis or at risk for psychosis: a 6-month follow-up.

Objective: To investigate short-term outcomes of a computer-assisted cognitive remediation (CACR) for adolescents with psychotic disorders or at high risk for psychosis.

Method: Cognitive abilities and clinical status were assessed at baseline (N = 32) and at 6-month follow-up (N = 22) after enrolment in either a CACR (treatment group) or a computer games (control group) program (8 weeks).

Results: With regard to the cognitive abilities, no amelioration was found in the control group while, in the CACR group, significant improvements in inhibition (p = 0.040) and reasoning (p = 0.005) were observed. Furthermore, symptom severity decreased significantly in the control group (p = 0.046) and marginally in the CACR group (p = 0.088). Improvements in cognitive abilities were not associated with symptoms' amelioration. Finally, increase in reasoning abilities was related to the median effective work time in sessions of CACR (R = 0.64, p = 0.024).

Conclusion: At follow-up, enhanced cognitive abilities (reasoning and inhibition), which are necessary for executing higher-order goals or adapting behaviour to the ever-changing environment, were reported in adolescents participants of the CACR. Thus, further studies are needed to confirm and extend these interesting results.

Cognitive efficacy of quetiapine in early-onset first-episode psychosis: a 12-week open label trial

Twenty-three adolescents with psychotic disorders, aged from 13 to 18 years, participated in a 12-week open label trial (17 adolescents completed the study) in order to examine the impact of quetiapine on clinical status and cognitive functions (encompassing processing speed, attention, short-term memory, long-term memory and executive function). An improvement in Clinical Global Impression and Positive and Negative Symptom Scale (P's ≤ 0.001) was observed. In addition, after controlling for amelioration of symptoms, a significant improvement was observed on one executive function (P = 0.044; Trail Making Part B). The remaining cognitive abilities showed stability. In addition, we observed an interaction between quetiapine doses (>300 mg/day or <300 mg/day) and time, where lower doses showed more improvement in verbal short-term memory (P = 0.048), inhibition abilities (P = 0.038) and positive symptoms (P = 0.020). The neuropsychological functioning of adolescents with psychotic disorders remained mainly stable after 12 weeks of treatment with quetiapine. However, lower doses seemed to have a better impact on two components of cognition (inhibition abilities and verbal short-term memory) and on positive symptoms.

Quetiapine in adolescents with non-affective psychotic disorders: an open-label trial

INTRODUCTION

There is a need for more studies on the clinical effectiveness, tolerability and pharmacokinetics of atypical antipsychotics in adolescents with psychotic disorders, as this represents a vulnerable and difficult population to treat. According to recent concerns regarding disabling side effects of antipsychotics, particularly weight gain, further monitoring of their safety profiles is needed. This situation prompted the authors to carry out an investigation on the clinical effectiveness of quetiapine in psychotic adolescents.

METHODS

23 adolescents (13-18 years old) with psychotic disorders participated in a 12-week open label trial, including 6 visits assessing clinical efficacy, tolerability and safety of quetiapine (50-750 mg daily).

RESULTS

Adolescents were treated with lower doses compared to adults. Significant decreases in CGI and PANSS total scores were observed after both 4 and 12 weeks of quetiapine treatment compared to baseline. Sedation was the main adverse effect, but medication was generally well tolerated. Irregular compliance, (as assessed by pill counts, a questionnaire and by plasma quetiapine concentration monitoring), and alcohol and/or cannabis consumption were factors identified in this study which add to the difficulty in treating this population.

DISCUSSION

The results of the present study help to consolidate evidence of the usefulness of quetiapine as a treatment for adolescents with psychotic disorders. However, this study also highlights the issues encountered in treating this group, including the presence of comorbidities such as drug abuse.

LECs Made of m-Lppp

We report the application of the blue light emitting conjugated polymer m-LPPP (methyl substituted laddertype poly(paraphenylene) ) in light emitting electrochemical cells. The active layer of the LEC consists of a blend of m-LPPP with the ionically conductive polymer PEO and LiCF3SO3 as ionic salt. Investigations of different concentrations of PEO and salt showed that the best LECs made of m-LPPP up to now where realised with an active layer consisting of a blend of m-LPPP:PEO:salt in the range of 20:10:3. In this case we are able to realise LECs with response times in the range of 30 μs. The I/U characteristics show low turn on voltages both for current and electroluminescence, but only in the case of ITO biased as a cathode. The initial electroluminescence spectra are quite the same as those for LEDs made of m-LPPP but turn into green after some time of operation.

Dynamics of two trapped Brownian particles: Shear-induced cross-correlations

The dynamics of two Brownian particles trapped by two neighboring harmonic potentials in a linear shear flow is investigated. The positional correlation functions in this system are calculated analytically and analyzed as a function of the shear rate and the trap distance. Shear-induced cross-correlations between particle fluctuations along orthogonal directions in the shear plane are found. They are linear in the shear rate, asymmetric in time, and occur for one particle as well as between both particles. Moreover, the shear rate enters as a quadratic correction to the well-known correlations of random displacements along parallel spatial directions. The correlation functions depend on the orientation of the connection vector between the potential minima with respect to the flow direction. As a consequence, the inter-particle cross-correlations between orthogonal fluctuations can have zero, one or two local extrema as a function of time. Possible experiments for detecting these predicted correlations are described.

Direct measurement of shear-induced cross-correlations of Brownian motion

Shear-induced cross-correlations of particle fluctuations perpendicular and along streamlines are investigated experimentally and theoretically. Direct measurements of the Brownian motion of micron-sized beads, held by optical tweezers in a shear-flow cell, show a strong time asymmetry in the cross-correlation, which is caused by the non-normal amplification of fluctuations. Complementary measurements on the single particle probability distribution substantiate this behavior and both results are consistent with a Langevin model. In addition, a shear-induced anticorrelation between orthogonal random displacements of two trapped and hydrodynamically interacting particles is detected, having one or two extrema in time, depending on the positions of the particles.

[Integration processes and clinical governance in the psychiatric network]

The Swiss Medical Insurance Act (LAMaL) requires the planning of psychiatric care. This necessitates a coordination between the Department of Public Health and the institutional governance. Given the difficulties to draw comparisons between a wide range of systems in a federal country, the Swiss Conference of the State Directors of Health (CDS) proposed as a first step that each canton present some of the key programs they had developed. In the canton Vaud, the implementation of mobile community treatment teams and of an early intervention program for psychosis was chosen. The main challenges faced were to go past traditional divides within the organisation of the Swiss Health system and to conciliate the requirements of public health with the needs of treating teams, in order to promote early intervention in mental health disorders.

[Psychiatric mobile teams for the three ages of live: the Lausanne experience]

Mobile teams have been developed for the three ages to meet the needs of people who should receive--but do not access to--a psychiatric assessment or to specialized care. To achieve this goal, the teams built a strong partnership within the social network, both with relatives and professionals involved. The general principles of intervention are similar between the ages: a focused target population, assertive outreach which benefits also relatives and carers, multidisciplinary teams with a limited caseload to ensure availability. The specificities of each age will be analyzed.

[Adolescent psychosis, can neuroscience improve prediction?]

Developments in the field of neuroscience have created a high level of interest in the subject of adolescent psychosis, particularly in relation to prediction and prevention. As the medical practice of adolescent psychosis and its treatment is characterised by a heterogeneity which is both symptomatic and evolutive, the somewhat poor prognosis of chronic development justifies the research performed: apparent indicators of schizophrenic disorders on the one hand and specific endophenotypes on the other are becoming increasingly important. The significant progresses made on the human genome show that the genetic predetermination in current psychiatric pathologies is complex and subject to moderating effects and there is therefore significant potential for nature-nurture interactions (between the environment and the genes). The road to be followed in researching the phenotypic expression of a psychosis gene is long and winding and is susceptible to many external influences at various levels with different effects. Neurobiological, neurophysiological, neuropsychological and neuroanatomical studies help to identify endophenotypes, which allow researchers to create identifying "markers" along this winding road. The endophenotypes could make it possible to redefine the nosological categories and enhance understanding of the physiopathology of schizophrenia. In a predictive approach, large-scale retrospective and prospective studies make it possible to identify risk factors, which are compatible with the neurodevelopmental hypothesis of schizophrenia. However, the predictive value of such markers or risk indicators is not yet sufficiently developed to offer a reliable early-detection method or possible schizophrenia prevention measures. Nonetheless, new developments show promise against the background of a possible future nosographic revolution, based on a paradigm shift. It is perhaps on the basis of homogeneous endophenotypes in particular that we will be able to understand what protects against, or indeed can trigger, psychosis irrespective of the clinical expression or attempts to isolate the common genetic and biological bases according to homogeneous clinical characteristics, which have to date, proved unsuccessful.

Detection of cognitive impairment with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) in adolescents with psychotic symptomatology

Cognitive impairment has been identified in the early phase of schizophrenia spectrum disorders, and is a major contributor to disease-related disability. While screening tools assessing cognitive impairment have been validated for adult schizophrenic populations, there is a need for brief, easily administered, standardized instruments that provide clinically relevant information for adolescents. This study examines the utility of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) in identifying and quantifying neurocognitive impairment in adolescents with schizophrenia spectrum disorders and other serious psychiatric illnesses. 112 adolescents, including 32 healthy subjects and 80 patients, were administered the RBANS. Patients with psychotic disorders demonstrated significant impairment on the RBANS total score compared to patients with other disorders and healthy controls, but this impairment appeared somewhat less severe than is typically reported for in adult patients with schizophrenia on this measure. The RBANS appears to be sensitive in the detection of neurocognitive impairment in a psychiatric population of adolescents with psychotic symptomatology, and may therefore have utility as a clinical screening instrument and/or neurocognitive outcome measure in this population.

Cryo-FIB-nanotomography for quantitative analysis of particle structures in cement suspensions

Cryo-FIB-nanotomography is a novel high-resolution 3D-microscopy technique, which opens new possibilities for the quantitative microstructural analysis of complex suspensions. In this paper, we describe the microstructural changes associated with dissolution and precipitation processes occurring in a fresh cement paste, which has high alumina and sulphate contents. During the first 6 min, precipitation of ettringite leads to a general decrease of the particle size distribution. In the unhydrated cement paste almost no particles smaller than 500 nm are present, whereas after 6 min this size class already represents 9 vol%. The precipitation of ettringite also leads to a significant increase of the particle number density from 0.294*10(9)/mm(3) at t(0min) to 20.55*10(9)/mm(3) at t(6min). Correspondingly the surface area increases from 0.75 m(2)/g at t(0min) to 2.13 m(2)/g at t(6min). The small ettringite particles tend to form agglomerates, which strongly influence the rheological properties. The particular strength of cryo-FIB-nt is the potential to quantify particle structures in suspension and thereby also to describe higher-order topological features such as the particle-particle interfaces, which is important for the study of agglomeration processes.

Adolescent substance-use assessment: methodological issues in the use of the Adolescent Drug Abuse Diagnosis (ADAD)

During the past twenty years, various instruments have been developed for the assessment of substance use in adolescents, mainly in the United States. However, few of them have been adapted to, and validated in, French-speaking populations. Consequently, although increasing alcohol and drug use among teenagers has become a major concern, the various health and social programs developed in response to this specific problem have received little attention with regard to follow-up and outcome assessment. A standardized multidimensional assessment instrument adapted for adolescents is needed to assess the individual needs of adolescents and assign them to the most appropriate treatment setting, to provide a single measurement within and across health and social systems, and to conduct treatment outcome evaluations. Moreover, having an available instrument makes it possible to develop longitudinal and transcultural research studies. For this reason, a French version of the Adolescent Drug Abuse Diagnosis (ADAD) was developed and validated at the University Child and Adolescent Psychiatric Clinic in Lausanne, Switzerland. This article aims to discuss the methodological issues that we faced when using the ADAD instrument in a 4-year longitudinal study including adolescent substance users. Methodological aspects relating to the content and format of the instrument, the assessment administration and the statistical analyses are discussed.

Adolescent Drug Abuse Diagnosis (ADAD) vs. Health of Nation Outcome Scale for Children and Adolescents (HoNOSCA) in clinical outcome measurement

BACKGROUND

The Adolescent Drug Abuse Diagnosis (ADAD) and Health of Nation Outcome Scales for Children and Adolescents (HoNOSCA) are both measures of outcome for adolescent mental health services.

AIMS

To compare the ADAD with HoNOSCA; to examine their clinical usefulness.

METHODS

Comparison of the ADAD and HoNOSCA outcome measures of 20 adolescents attending a psychiatric day care unit.

RESULTS

ADAD change was positively correlated with HoNOSCA change. HoNOSCA assesses the clinic's day-care programme more positively than the ADAD. The ADAD detects a group for which the mean score remains unchanged whereas HoNOSCA does not.

CONCLUSIONS

A good convergent validity emerges between the two assessment tools. The ADAD allows an evidence-based assessment and generally enables a better subject discrimination than HoNOSCA. HoNOSCA gives a less refined evaluation but is more economic in time and possibly more sensitive to change. Both assessment tools give useful information and enabled the Day-care Unit for Adolescents to rethink the process of care and of outcome, which benefited both the institution and the patients.

Le refus scolaire

Pediatrician are often questioned by school refusal which relies on a wide range of psychopathological features and necessitates specific approaches. This disabling condition remains underestimated and is still increasing. A poor prognosis associated with a prolonged school absence is the common hallmark of school refusals, regardless of its heterogeneity. Its seriousness warrants early identification and prompt intervention by childhood healthcare professionals, teachers and social workers. A specialized treatment is needed, closely linked with families and school. Promising developments come from a functional rather than symptomatic concept of school refusal. They offer tailored interventions which fit the clinical diversity of school refusals. After a brief historical summary and current definitions of school refusal, the authors review the main clinical features and comorbidity before taking up treatment modalities.

Risperidone-induced symptomatic hyperprolactinaemia in adolescents

Studies performed in adult patients unambiguously demonstrate a marked effect of risperidone on prolactin blood levels, with possible clinical effects related to hyperprolactinemia, such as gynecomastia and galactorrhea. However, the largest study performed in children and adolescents showed a weak effect of risperidone on prolactin concentrations during short-term treatment and a negligible effect during long-term treatment, which was probably because of the relatively low dosages of risperidone used [approximately 0.04 mg/(kg x d)]. Among the 10 psychotic adolescents treated with risperidone in our unit, we had 3 cases of gynecomastia in 3 male patients and 2 cases of galactorrhea in 2 female patients. The prolactin blood levels in these cases and in 3 other patients without apparent prolactin-related side effects were all above the normal range (median, 59 ng/mL; range, 30-123 ng/mL). Thus, risperidone administered to adolescents at doses commonly used for the treatment of psychotic symptoms can strongly increase prolactin levels, with clinical consequences such as gynecomastia and/or galactorrhea. Given that the long-term effects of antipsychotic drug-induced hyperprolactinemia are not well documented, especially regarding osteopenia, infertility, growth, and pubertal delay, risperidone should be administered with caution to children and adolescents.

Aripiprazole and suicidality

Cases of psychotic symptoms that worsen after treatment with aripiprazole have been described. We report the case of a 19-year-old patient who, although her psychotic symptoms did not worsen, attempted suicide after switching from risperidone to aripiprazole. The patient had not shown any aggressive behaviour towards herself or others in the 18 months before the introduction of aripiprazole, nor following its discontinuation (12 months). The observed time sequence, with the repetition 4 weeks later of high suicidal behaviour, led us to consider that this effect might possibly be linked to the aripiprazole treatment, which could have increased the risk of suicide in this patient.

Community Introduction of Practice Parameters for Autistic Spectrum Disorders: Advancing Early Recognition

OBJECTIVES

Within a strong interdisciplinary framework, improvement in the quality of care for children with autistic spectrum disorders through a 2 year implementation program of Practice Parameters, aimed principally at improving early detection and intervention.

METHOD

We developed Practice Parameters (PPs) for Pervasive Developmental Disorders and circulated the PPs to all child and adolescent psychiatrists practicing in the region.

RESULTS

PP development and parallel information strategies resulted in a significant decrease of 1.5 years in the mean-age-at-diagnosis. However, further analysis indicated that improvement was only transient.

CONCLUSION

Despite the encouraging improvement in mean-age-at-diagnosis 2 years after PP implementation, other indicators showed a failure to maintain the improvements. A systematic screening program would be the most reliable method to reinforce the PPs.

Adolescent substance-use assessment: methodological issues in the use of the ADAD (Adolescent Drug Abuse Diagnosis)

During the past twenty years, various instruments have been developed for the assessment of substance use in adolescents, mainly in the United States. However, few of them have been adapted to, and validated in, French-speaking populations. Consequently, although increasing alcohol and drug use among teenagers has become a major concern, the various health and social programs developed in response to this specific problem have received little attention with regard to follow-up and outcome assessment. A standardized multidimensional assessment instrument adapted for adolescents is needed to assess the individual needs of adolescents and assign them to the most appropriate treatment setting, to provide a single measurement within and across health and social systems, and to conduct treatment outcome evaluations. Moreover, having an available instrument makes it possible to develop longitudinal and trans-cultural research studies. For this reason, a French version of the Adolescent Drug Abuse Diagnosis (ADAD) was developed and validated at the University Child and Adolescent Psychiatric Clinic in Lausanne, Switzerland. This paper aims to discuss the methodological issues that we faced when using the ADAD instrument in a 4-year longitudinal study including adolescent substance users. Methodological aspects relating to the content and format of the instrument, the assessment administration and the statistical analyses are discussed.

Three-dimensional analysis of porous BaTiO3 ceramics using FIB nanotomography

Three-dimensional (3D) data represent the basis for reliable quantification of complex microstructures. Therefore, the development of high-resolution tomography techniques is of major importance for many materials science disciplines. In this paper, we present a novel serial sectioning procedure for 3D analysis using a dual-beam FIB (focused ion beam). A very narrow and reproducible spacing between the individual imaging planes is achieved by using drift correction algorithms in the automated slicing procedure. The spacing between the planes is nearly of the same magnitude as the pixel resolution on scanning electron microscopy images. Consequently, the acquired stack of images can be transformed directly into a 3D data volume with a voxel resolution of 6 x 7 x 17 nm. To demonstrate the capabilities of FIB nanotomography, a BaTiO3 ceramic with a high volume fraction of fine porosity was investigated using the method as a basis for computational microstructure analysis and the results compared with conventional physical measurements. Significant differences between the particle size distributions as measured by nanotomography and laser granulometry indicate that the latter analysis is skewed by particle agglomeration/aggregation in the raw powder and by uncertainties related to calculation assumptions. Significant differences are also observed between the results from mercury intrusion porosimetry (MIP) and 3D pore space analysis. There is strong evidence that the ink-bottle effect leads to an overestimation of the frequency of small pores in MIP. FIB nanotomography thus reveals quantitative information of structural features smaller than 100 nm in size which cannot be acquired easily by other methods.