Encephale
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Practice Guideline Guideline
[Guidelines for substitution treatments in prison populations].
Care access for the drug addict patients in prison (in particular for the treatments of substitution) in France is very unequal from one establishment to another. This reflects the great variability of the practices of substitution and especially the absence of consensus on the methods of adaptation of these practices to the prison environment. Because of difficulties expressed by prisoners and medical staff on this subject and of stakes (let us recall that approximately 30% of the prisoners are dependent or abusers of one or more psychoactive substances), the formulation of recommendations or of a good practices guide of substitution in prison appeared necessary. ⋯ The report of joint mission IGAS/IGSJ of June 2001 on the health of the prisoners underlines the principal persistent gaps: hygiene and public health, treatment of the mental disorders, the follow-up of the sexual delinquents, handling ageing, handicap and the end of lifetime. In the same way, the difficulties listed in prison environment concerning substitution are only the exacerbation of those existing outside: the misuses and traffics are common in free environment, risk reduction in prison, as outside, handle with obstacles related to the penalization of the drug use and can hardly evolve except questioning the law of 1970. The prison practice opens also questions: that of the "duration" of the substitution, frequently posed by the prisoners; concern to see the prison becoming a privileged place of access to the care, combining sanction and care whereas the law of 1970 allows the alternative (care or sanction); that of the clinic of the misuse, particularly "readable" in prison environment; and finally the question of the shared secrecy, extremely delicate in prison context although clarified by the law of March 04, 2002.
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For schizophrenic disorders, the clinical conception of "acute state" is widely used in clinical settings to assess the effectiveness of therapeutic programs as well as epidemiological studies. Schizophrenic-specific symptomatology modification, need for hospitalization, significant change in care, disturbances in social behavior or suicide attempts were all used to define acute schizophrenic state. The decision to hospitalize is frequently used to define acute state but refers to multiple factors such as mood disorder, suicide attempts, drug abuse or social and environmental problems. ⋯ Hallucinatory behavior is the first symptom rated in definition and is considered by psychiatrists as the absolute therapeutic priority. This survey could be a first step in the construction of an operational and consensual definition. This definition is strongly needed as a valid measurement in therapeutic and epidemiological outcome studies, which remain at least partly based on clinician subjective judgment.
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Knowledge of cognitive performance earlier in life is essential in order to characterize precisely the extent to which these abilities have declined when an individual is diagnosed as having a dementing illness. The National Adult Reading Test (NART) was developed by Nelson and O'Connell to estimate premorbid intellectual ability in patients suffering from intellectual deterioration due to dementia. The test consists of 50 words, graded in difficulty, whose pronunciation cannot be determined from their spelling. The ability to successfully read irregularly spelt words is relatively robust in the face of current cognitive impairment and is a sensitive marker of intellectual attainment. Because the NART relies on orthographic irregularities in the English language, the construction of analogues of the test in other languages is not simply a matter of translation of the test content. Rather, words in the target language that have comparable properties to those in the NART must be sought. A French adaptation of the NART--the fNART--was developed by Bovet and calibrated on a small French-speaking Swiss sample. In a sample of 30 nondemented subjects, number of words pronounced correctly correlated highly with WAIS-R verbal and total IQ scores and less strongly with performance IQ (r = 0.43). Data available from an epidemiological survey undertaken in Geneva, Switzerland provided an opportunity to establish the measurement properties and construct validity of the fNART in a large sample unselected with respect to cognitive decline. In addition to the fNART, the survey incorporated a brief test battery assessing the domains of crystallized intelligence, memory and cognitive speed. An interview that enabled the diagnosis of dementia according to DSM IV criteria, the Mini Mental State Examination and the Psychogeriatric Assessment Scales (PAS) were also administered. If the fNART measures intellectual ability, substantial correlations between it and the test battery would be expected. Further validation of the test was sought by exploring its relation with years of education. The stability of the fNART was assessed by comparing the scores of subjects with and without dementia, and by examining the relationship of fNART scores to an informant-based report of change in cognitive performance from earlier in life assessed in the PAS. If the fNART is stable in the face of cognitive deterioration, no between-group differences or association with reported cognitive change would be expected. ⋯ Further research is desirable to improve the precision of the calibration of the scale against the WAIS-R. Nevertheless, this study has demonstrated that the fNART is a reliable and valid method of assessing premorbid intellectual ability in French speakers.