Is electrodiagnosic testing for polyneuropathy overutilized?

Distal symmetric polyneuropathy (DSP) is one of the most common problems seen in clinical practice and one of the most frequent reasons for electrodiagnostic (EDx) testing. Most studies have supported the use of EDx testing for patients with suspected DSP. Some recent articles assert that EDx testing has a low yield in suspected DSP and is only needed for atypical presentations (a minority). However, many peer‐reviewed articles indicate that EDx frequently changes diagnosis and management, and leads to a better understanding of the underlying pathology, severity, and prognosis. Overall, EDx is appropriate for most patients with new signs and symptoms of DSP. Muscle Nerve 55 : 301–304, 2017     

Epidemiology and genetics of cluster headache

Cluster headache, the most severe primary headache, is characterised by unilateral pain, ipsilateral autonomic features, and, in many cases, restlessness. Recent epidemiological studies indicate that the prevalence of cluster headache is about one person per 500. Genetic epidemiological surveys indicate that first-degree relatives are five to 18 times-and second-degree relatives, one to three times-more likely to have cluster headache than the general population. Inheritance is likely to be autosomal dominant with low penetrance in some families, although there may also be autosomal recessive or multifactorial inheritance in others. To date, no molecular genetic clues have been identified for cluster headache. Identification of genes for cluster headache is likely to be difficult because most families reported have few affected members and genetic heterogeneity is likely. Future focus should be on ion channel genes and clock genes. This review summarises the epidemiology and genetics of cluster headache.     

An update in the management of obesity: the weight of CNS targets

Obesity is one of the most important and disturbing global epidemic that affects humans, with more than 2 billion people overweight and 700 million obese predicted for 2015 by the World Health Organization. Obesity treatment represents then one of the most exciting challenges for the academic researchers and the pharmaceutical industry. But to date, this community failed to develop safe and effective treatments with a good risk/benefit profile. Indeed, most of the drugs previously used as anti-obesity agents have been withdrawn from the market for safety issues, and therapeutic options in form of a medication are currently very limited. This last decade however, new advances in our understanding of central pathways controlling food intake, body weight and energy homeostasis have led to the discovery of new molecular targets that could provide interesting options in the fight against obesity. This review aims to be an overview of the new patents exploiting the anorexigenic properties of the central catabolic pathways or aimed at blocking the orexigenic effects of the anabolic pathways, in the hope to develop new anti-obesity drugs.     

Incomplete remission in depression: role of psychiatric and somatic comorbidity

Depression is one of the most pressing public health issues, because of its high lifetime prevalence and because it is associated with substantial disability. In depressed patients, psychiatric and medical comorbidity is the rule rather than the exception. About 60% to 70% of depressed patients have at least one, while 30% to 40% have two or more, concurrent psychiatric disorders. Among these, anxiety disorders and substance use disorders are the most common axis I comorbidities. Furthermore, two thirds of depressed patients have at least one comorbid medical illness. Among depressed patients, those with a current comorbid psychiatric condition (in particular an anxiety or substance use disorder) or medical illness seem to have an impaired response and remission rate during treatment compared with those patients without comorbidity. However, in depressed patients who all have the same comorbid condition, the relative benefit of an antidepressant compared with placebo appears to be equal to those effects achieved in depressed patients without comorbidity. These findings raise important research and treatment issues regarding the generalizability from randomized controlled trials that tend to exclude patients with comorbidity.     

Proposed diagnostic criteria for neurocysticercosis

Neurocysticercosis is the most common helminthic infection of the CNS but its diagnosis remains difficult. Clinical manifestations are nonspecific, most neuroimaging findings are not pathognomonic, and some serologic tests have low sensitivity and specificity. The authors provide diagnostic criteria for neurocysticercosis based on objective clinical, imaging, immunologic, and epidemiologic data. These include four categories of criteria stratified on the basis of their diagnostic strength, including the following: 1) absolute--histologic demonstration of the parasite from biopsy of a brain or spinal cord lesion, cystic lesions showing the scolex on CT or MRI, and direct visualization of subretinal parasites by funduscopic examination; 2) major--lesions highly suggestive of neurocysticercosis on neuroimaging studies, positive serum enzyme-linked immunoelectrotransfer blot for the detection of anticysticercal antibodies, resolution of intracranial cystic lesions after therapy with albendazole or praziquantel, and spontaneous resolution of small single enhancing lesions; 3) minor--lesions compatible with neurocysticercosis on neuroimaging studies, clinical manifestations suggestive of neurocysticercosis, positive CSF enzyme-linked immunosorbent assay for detection of anticysticercal antibodies or cysticercal antigens, and cysticercosis outside the CNS; and 4) epidemiologic--evidence of a household contact with Taenia solium infection, individuals coming from or living in an area where cysticercosis is endemic, and history of frequent travel to disease-endemic areas. Interpretation of these criteria permits two degrees of diagnostic certainty: 1) definitive diagnosis, in patients who have one absolute criterion or in those who have two major plus one minor and one epidemiologic criterion; and 2) probable diagnosis, in patients who have one major plus two minor criteria, in those who have one major plus one minor and one epidemiologic criterion, and in those who have three minor plus one epidemiologic criterion.     

The therapist's voice

We all have priceless things in our lives. Have you ever stopped to consider what is the most precious thing you have in the world? What is the one thing you have that if it were taken away, you would never be the same again? Think about it. Take a minute.

You may find that a particular relationship you have is the most precious thing in the world. Perhaps it is your health and the health of those around you that is most precious. Perhaps you have a different answer, though when you consider this question very carefully, is there not something that takes priority over it all?

I would suggest that our awareness is our most priceless gift. We usually take it for granted. Indeed the only reason anything is precious to us is because we are aware of its value

David Cooper, adapted from God is a Verb. p. 32, 1997.     

Secondary paroxysmal dyskinesias.

Paroxysmal dyskinesias (PxDs) are involuntary, episodic movements that include paroxysmal kinesigenic (PKD), paroxysmal nonkinesigenic (PNKD), and paroxysmal hypnogenic (PHD) varieties. Although most PxDs are primary (idiopathic or genetic), we found 17 of our 76 patients with PxD (22%) to have an identifiable cause for their PxD (10 men; mean age, 41.4 years). Causes included peripheral trauma (in three patients), vascular lesions (in four), central trauma (in four), kernicterus (in two), multiple sclerosis (in one), cytomegalovirus encephalitis (in one), meningovascular syphilis (in one), and migraine (in one). The latency from insult to symptom onset ranged from days (trauma) to 18 years (kernicterus), with a mean of 3 years. Nine patients had PNKD, two had PKD, five had mixed PKD/PNKD, and one had PHD. Hemidystonia was the most common expression of the paroxysmal movement disorder, present in 11 patients. Both of the patients with PKD had symptom durations of <5 minutes. Symptom duration ranged from 10 seconds to 15 days for PNKD and from 5 minutes to 45 minutes for mixed PKD/PNKD. There were no uniformly effective therapies, but anticonvulsant drugs, clonazepam, and botulinum toxin injections were the most beneficial. Awareness of the variable phenomenology and the spectrum of causes associated with secondary PxD will allow for more timely diagnosis and early intervention.     

Modalities of treatment for suicidal children: an overview of the literature on current practice

Childhood suicidal behavior is a complex symptom that requires a carefully planned treatment program that includes multiple modalities of care. These modalities combine individual, family, environmental, and psychopharmacological interventions. The therapist's personal conscious and unconscious characteristics may have a great influence on treatment outcome. A supportive patient-therapist relationship is one of the most important elements in diminishing the child's suicidal proclivities. Treatment requires a long-term approach that constantly reassesses potential for serious suicidal risk. Psychiatric hospitalization may be required to protect the child from self-inflicted harm and to allow evaluation and appropriate intervention. Psychotherapy used in conjunction with medication, when indicated, may permit the best therapeutic outcome. Finally, planning systematic studies of psychiatric treatment efficacy for suicidal children remains one of the most challenging aspects of improving prevention measures against suicidal tendencies in youngsters.     

Passions entre mystiques et folies

Passions and mystics develop multiple and complex relationships with each other. They can ignore each other, team up or fight each other for better or for worse. They have some common points but differ in their nature and their effects. If there are hardly passions without mysticism, even if only in traces, there are mystics without passions, as the most dramatic episodes in human history have always witnessed. In order to distinguish the passions, the mystics and the follies that they can generate from one another, the analysis of the object of desire that animates them, an object with often inconspicuous outlines, seemed to us the most appropriate means. The reflections which follow attempt to cross, at least in part, the often-deceptive appearances of this object whose identification can only be partial.     

Befriending: A Note of Caution

‘Our relationships define who we are as individuals’ (Kennedy & Itkonen, 1993) It is recognised that the quality and closeness of personal relationships underlie a fulfilled life. However, services for people with learning disabilities often find this aspect of human life the most difficult to promote. Recently, befriending schemes have represented one initiative designed to fill the gap. This paper follows the progress of one pilot project and its outcomes for four participants with learning disabilities. It is concluded that caution should be exercised in any similar scheme, and that careful monitoring should ensure that new relationships are not being formed at the expense of prior, possibly less transient ones.     

Psychotherapy: confusion in language

Psychiatry has to make choices in the wide range of psychotherapies. A good classification however permits to distinguish those that are of personal development, those that have mainly a political significance of those that have really a clinical use. The psychoanalytic model keeps being the most useful one for understanding the psychiatric patients and for their treatment. Researches should be undertaken to adapt the model to more realistic issues. Short-term analytic psychotherapies should be tested in adapted settings, with emphasis on focal problems, present unconscious stresses and limited goals.     

The Career Patterns of Persons with Serious Mental Illness: Generating a New Vision of Lifetime Careers for those in Recovery

Abstract

This article reviews the findings from two small scale studies - one quantitative and one qualitative - that examined the career patterns of persons with serious mental illness, in which consumers reported on the types of jobs, wages and benefits, job duration, job satisfaction, and reasons for job changes throughout their careers. Both studies report that consumers have held many jobs, often successfully, and often stayed at their jobs for periods of time roughly comparable to their non-disabled co-workers. However, because most jobs were in entry-level and low-wage fields, these long-term career patterns were often marked by little economic progress. The authors suggest that the vocational rehabilitation field needs to reconceptualize both the past careers of this population and the careers that many of those with serious mental illness will be likely to have in the future.     

Diffuse axonal injury: Novel insights into detection and treatment

Diffuse axonal injury (DAI) is one of the most common and important pathologic features of traumatic brain injury. The definitive diagnosis of DAI, especially in its early stage, is difficult. In addition, most therapeutic agents for patients with DAI are non-specific. The CT scan is widely used to identify signs of DAI. Although its sensitivity is limited to moderate to severe DAI, it remains a useful first-line imaging tool that may also identify co-morbid injuries such as intracerebral hemorrhage. Recently, investigations have sought to apply advanced imaging techniques and laboratory techniques to detect DAI. Meanwhile, some potential specific treatments that may protect injured axons or stimulate axonal regeneration have been developed. We review some new diagnostic technologies and specific therapeutic strategies for DAI.     

Cure therapeutics and strategic prevention: raising the bar for mental health research

Mental disorders cause more disability than any other class of medical illness in Americans between ages 15 and 44 years. The suicide rate is higher than the annual mortality from homicide, AIDS, and most forms of cancer. In contrast to nearly all communicable and most non-communicable diseases, there is little evidence that the morbidity and mortality from mental disorders have changed in the past several decades. Mental health advocates, including psychiatric researchers, have pointed to stigma as one of the reasons for the lack of progress with mental illnesses relative to other medical illnesses. This review considers how the expectations and goals of the research community have contributed to this relative lack of progress. In contrast to researchers in cancer and heart disease who have sought cures and preventions, biological psychiatrists in both academia and industry have set their sights on incremental and marketable advances, such as drugs with fewer adverse effects. This essay argues for approaches that can lead to cures and strategies for prevention of schizophrenia and mood disorders.     

Neuropsychological research in delusional disorder: a comprehensive review

In recent decades, there has been a growing interest in the field of delusions, and different aspects of delusional disorder (DD) have been investigated. However, DD is still one of the most underresearched psychiatric disorders. In this paper, we review the literature on DD and most of the theoretical approaches proposed to explain the development and maintenance of delusions. DD research is infrequent, and delusions in this disorder have been scarcely investigated. We aim to establish the state of the art of delusions research to date and point to the shortage of neuropsychological studies in patients with DD. We also justify the need for future research into the neuropsychological correlates of DD as measured in patients with this disorder given that most previous research has mainly focused on other psychotic conditions.     

Service and patient predictors of continuation in clinic-based treatment

The authors studied 125 chronic patients who entered treatment at five community mental health clinics to identify the patient and service predictors of continuation in treatment. Patients who remained in treatment at the end of one year were significantly more likely than those who dropped out to have received medication at early visits, to have participated in psychotherapy, and to be chronically psychotic. Analysis of the clinics that most successfully retained patients in treatment indicated that service characteristics rather than patient characteristics accounted for the clinics' success. The authors discuss the treatment programs at the two most successful clinics and the implications of the findings for community clinics.     

Gene- and viral-based therapies for brain tumors

Advances in understanding and controlling genes and their expression have set the stage to alter genetic material to fight or prevent disease with brain tumors being among one of the first human malignancies to be targeted by gene therapy. All proteins are coded for by DNA and most neoplastic diseases ultimately result from the expression or lack thereof with one or more proteins (e.g., coded by oncogenes or tumor suppressor genes, respectively). In theory, therefore, diseases could be treated by expression of the appropriate protein in the affected cells. Gene therapy is an experimental treatment that involves introducing genetic material (DNA or RNA) into cells, and it has made important advances in the past decade. Within this short time span, it has moved from the conceptual laboratory research stage to clinical translational trials for brain tumors. The most efficient approaches for gene delivery are based on viral vectors, which have been proven relatively safe in the CNS, despite occasional cases of morbidity and death in non-neurosurgical trials. However, the human response to various viral vectors can not be predicted in a reliable manner from animal experimentation, nor can size, consistency, and extent of experimental brain tumors in mouse models reflect the large, necrotic, infiltrative nature of malignant gliomas. Furthermore, the problem of delivering genetic vectors into solid brain tumors and the efficiency in situ gene transfer remains one of the most significant hurdles in gene therapy.     

Parkinson’s disease: The treatment of drug-induced hallucinations and psychosis

Drug-induced psychosis is one of the most disabling complications of advancing Parkinson’s disease. It has also been one of the most difficult to treat. Clozapine was the first medication shown to be safe and effective in this setting, and it remains the standard by which newer atypical antipsychotics are measured. However, due to the small but significant risk of agranulocytosis and the need for frequent blood testing, alternatives have been sought. Risperidone, olanzapine, and quetiapine are new atypical antipsychotics that have each been proposed as an alternative to clozapine, but the literature concerning their use in Parkinson’s disease is conflicted and confusing. Although quetiapine appears to be the best current choice, none of these medications have equaled clozapine’s ability to safely treat drug-induced psychosis without the risk of worsening parkinsonism.     

Subcortical arteriosclerotic encephalopathy (Binswanger's disease). Computed tomographic, nuclear magnetic resonance, and clinical correlations

Twenty-three elderly patients were found to have a consistent pattern of leukoencephalopathy by computed tomography and nuclear magnetic resonance imaging. Eight patients presented with vague, nonspecific symptoms and had no neurologic deficits. The other 15 patients had neurologic deficits that presented in one of three ways: stroke, seven patients; slowly progressive dementia and gait disturbance, five patients; or slowly progressive dementia alone, three patients. Risk factors for arteriosclerosis (hypertension, diabetes) were present in 18 patients (78%). The necropsy of one patient revealed arteriosclerotic vasculopathy characteristic of subcortical arteriosclerotic encephalopathy (SAE) or Binswanger's disease. Subcortical arteriosclerotic encephalopathy may be a relatively common affliction of elderly patients, most of whom have risk factors for arteriosclerosis. The modes of presentation and associated clinical signs are variable, and more than one third may have no neurologic deficit. In some cases SAE overlaps with normal pressure hydrocephalus by clinical and neuroimaging criteria. Some patients with normal pressure hydrocephalus who do not respond to ventricular shunting may actually have SAE.     

Foot structure in Japanese speech errors: Normal vs pathological

Although many studies of speech errors have been presented in the literature, most have focused on errors occurring at either the segmental or feature level. Few, if any, studies have dealt with the prosodic structure of errors. This paper aims to fill this gap by taking up the issue of prosodic structure in Japanese speech errors, with a focus on the foot level. The 501 speech errors from normal spontaneous speech of Japanese speakers will be compared with those collected from five aphasic patients. The acquisition data of Japanese supports the unmarkedness of foot binarity. Two types of evidence have been presented for this: bimoraic minimality effects in monomoraic lexical items, and disyllabic maximality effects of multisyllabic words. An analysis of the speech errors in normal speech also shows a similar tendency. If one focuses on the deletion/insertion data, one finds that foot binarity plays a crucial role in predicting the site where deletion/insertion occurs. It was found that, in most cases, deletion/insertion of morae (syllables) occurs as a repair strategy at the foot level. A preliminary study of the pathological data of the aphasic patients also indicates that foot binarity plays a role in accounting for this type of data. It is concluded that the results obtained from acquisitional and pathological data strongly support the unmarked status of binary feet.