The place of tranquillisers in the management of stress

There is good evidence that many types of tranquilliser are effective in treating anxiety disorders that result from stress, but this evidence is not sufficient to recommend their use for acute stress disorders. Although there is little doubt that they will relieve the mood disturbance of severe mental and physical trauma, they may aid the process of denial. There is also a danger that short-term use of tranquillisers may progress to long-term dependence despite the initial intention of the prescriber. It is recommended that tranquillisers should be only used if the stress is severe enough to lead to marked changes in behaviour, is unpredicted and is likely to have a clear beginning and end. Benzodiazepines are usually the tranquillisers of choice but other drugs are available in patients prone to dependence.     

The failure of the diversion process: the impact of transferring of patients to state hospitals

The diversion of people with severe mental illness into the private sector is examined. The purpose of the diversion system is to reduce the number of admissions to the state hospitals by diverting patients into the private hospitals, which may offer more diverse treatment to these patients. Insurance is highlighted as an important factor in diverting patients from state hospitals. When the diversion system fails and the patient is transferred from the private sector to the state hospitals, continuity of care is disrupted. The failure of the diversion is more costly not only to the patient but to the federal and state governments as well. Policy issues such as cost to the mental health system and continuity of care are discussed.     

Model studies of mechanisms of the rhythmic activity of mammalian neurons

A model of electric excitability of mammalian neurons is developed based on described properties of the corresponding ionic currents. It is shown that these neurons may possess two types of rhythmic activity. The first type corresponds to the combination of the fast sodium and delayed potassium currents, the average period of membrane potential oscillations being 74 +/- 27 ms. The second type is determined by calcium and Ca-dependent potassium currents, and its interspike interval is equal to 850 +/- 40 ms. Two mechanisms of adaptation (elongation of the interspike interval) of rhythmic activity are predicted for these neurons. The former is determined by the fast potassium current and the latter is due to accumulation of calcium ions inside the cell and the development of Ca-dependent potassium conductance.     

脑血管病临床教学方法探讨

教学是临床工作重要的组成部分,是培养年轻医生成长的必要手段。神经病学和其他学 科相比知识体系更加复杂。脑血管疾病是最常见的中枢神经系统疾病,脑血管病教学的目的就是通 过临床实践、教学查房和讲座,让年轻医师在短时间内掌握脑血管病相关的基础和临床知识,并在 此基础上形成正确的诊疗思路,能跟踪国内外最新进展,将新的诊疗方法应用到临床工作中来,并 能在临床工作中发现问题,建立科研假说,进行科学研究,更好地指导下一步临床工作。本文介绍了 首都医科大学附属北京世纪坛医院神经内科脑血管病教学的临床体会。     

Comparison of the immunological properties of rat cerebral and aortic endothelium

The immunological properties of cerebral microvascular endothelium were directly compared with those of an extra-cerebral endothelium in vitro. Lymphocyte adhesion to cerebral endothelium is normally low, but is sensitive to induction by interferon-gamma (IFN gamma) and tumour necrosis factor-alpha (TNF alpha). Conversely adhesion to aortic endothelium is normally much higher but it is only marginally sensitive to induction by cytokines. Adhesion to both cell types is Ca2+ and Mg2+ dependent. Mitogen-activated lymphocytes bind more strongly to both endothelia, but adhesion to aortic endothelium is not enhanced further by activation of the endothelium. The observed low binding of lymphocytes to brain endothelium and its rapid induction by cytokines suggest a mechanism to explain why lymphocyte accumulation in brain is normally very low but rapidly increases during immune responses. Both cell types express similar levels of class I major histocompatibility complex (MHC) molecules, and this is enhanced by IFN gamma with similar responsiveness to different levels of IFN gamma. MHC class II molecules are absent from these cells but may be induced: although both endothelia respond to similar levels of cytokines, the surface density induced on brain endothelium is approximately 2- to 3-fold higher at all levels of IFN gamma.     

Management of refusal of medical treatment

As patients increasingly refuse medical and surgical treatment, the physician's response to this challenge to the healing-helping role is often extremely negative. Even though refusal may be felt by the patient as the only way to regain a measure of autonomy or control, such a response may have more to do with characteristic coping styles or interpersonal battles with the physician, staff, or family than with the treatment itself. Since management hinges on understanding the intrapersonal and interpersonal factors which contribute, it is essential to explore the meaning of the refusal. With reduction of the adversarial stance, the patient frequently regains enough sense of self to engage in a mutually cooperative effort. Even if the refusal stands, with understanding, the physician may be able to accept the patient's choice, and extrusion from the system upon which the patient is still dependent is avoided.     

Localization of alpha-synuclein to mitochondria within midbrain of mice

The interrelationship between alpha-synuclein (alpha-syn) and mitochondria is not clearly understood. Owing to the lack of the signal peptide and its predominant localization in the cytosol, alpha-syn is generally considered to affect mitochondrial function through some secondary effects. Contrary to this assumption, here, we show that a portion of alpha-syn is present in the membrane of mitochondria in normal dopaminergic neurons. The same profile is also found in other alpha-syn-positive neurons. Thus, binding to the membrane of mitochondria is the physiological nature of alpha-syn and might also contribute to the pathological role of this protein in the mitochondrial dysfunction in Parkinson's disease.     

Role of EEG in the diagnosis of brain death

Brain death diagnosis is based upon several clinical and paraclinical criteria that have been legally defined. There is a medico-legal protocol when brain death diagnosis is made in order to allow organ removal for a possible transplantation. In France, EEG or cerebral arteriography must legally be used to confirm a clinical brain death suspicion. There is a specific procedure to perform an EEG to confirm the diagnosis of brain death. However all the criteria have been made using conventional paper EEG, while numerized is now used. The comparison of EEG recording using both analogical and numerised acquisition allow us to report several recommendations to use EEG for brain death diagnosis.     

Loss of vision

Visual loss is not uncommon and many patients end up seeing neurologists because of it. There is a long list of possible causes but in most patients visual loss is associated with visual field loss. This means that for practical purposes the differential diagnosis can usually be narrowed down to a manageable shortlist by consideration of where in the visual pathway the lesion is likely to be, along with the time course of the visual loss. This article provides a practical approach to the diagnosis and appropriate investigation of such patients, dividing them into four groups: those in whom vision is lost transiently, acutely, subacutely (i.e., days to weeks) and over a longer time frame (months to years). In addition, there is a discussion of those patients in whom visual loss is not obviously accompanied by any visual field loss.     

Contribution of imaging to the diagnosis of Darier-Ferrand's cranio-facial dermatofibrosarcoma. Report of 2 cases

Dermatofibrosarcoma protubans of Darier-Ferrand is observed in about 0.1% of al malignant skin tumors. Head and face localization in uncommon, estimated to account for about 1 to 10% of all lesions. Relapse is frequent and metastasis in uncommon. Diagnosis is often made late. Surgery is the basic treatment. We report two cases of dermatofibrosarcoma of Darier-Ferrand with head and face localizations. In one case, the tumor extended inside the skull and spread to the superior longitudinal sinus. This is the only such reported case found in the literature. CT scan is more useful for studying the bony tables and the cranial content. MRI provides precision for soft tissue tumors and angio-MRI is particularly useful for analysing with accuracy vascular relations of the tumor.     

Regulation of glycogen in the dentate gyrus of the in vitro guinea pig hippocampus; effect of combined deprivation of glucose and oxygen

Mammalian brain glycogen is adequate to support oxidative metabolism for several minutes. The present studies were done primarily to develop the guinea pig hippocampal slice as a model for studying the function and regulation of that glycogen. Slice glycogen falls to 6 nmol/mg dry wt. during the first hour of incubation at 36 degrees C but during the next 3 h recovers to 20 nmol/mg dry wt., similar to in situ values. Glycogen concentration in the dentate gyrus molecular layer is double its value in the whole hippocampal slice, suggesting its distribution is related to metabolic demand. When both glucose and oxygen are removed from the medium, glycogen and ATP fall to 50% within 6 min. The glycogen fall is unaffected by prolonged calcium depletion or by 3-isobutyl 1-methylxanthine, an adenosine antagonist. It is markedly slowed by preincubating the slice with creatine, which also slows the fall in ATP. It is concluded that ATP breakdown and subsequent increased 5'-AMP is activating glycogen mobilization in this in vitro model of ischemia.     

The principles of effective case management of mental health services

This paper identifies ten principles or active ingredients of case management that are common to interventions that produced statistically significant positive outcomes for people with serious psychiatric disabilities. Twenty-two studies employing experimental or quasi-experimental designs were selected for inclusion in this review. The use of the principles for systems design is briefly discussed. The term case management is used throughout this article because it is the term that is used in the studies reviewed. We acknowledge that this term is considered pejorative to many people with psychiatric disabilities. People with psychiatric disabilities are not "cases" and they do not need to be "managed." A more accurate reflection of what this service entails is that it is the services or resources that are managed in order to help people reach their goals. Until a more appropriate title becomes globally recognized, the term should be used with sensitivity to the negative connotations it carries.     

From depths of despair to heights of recovery

While disclosure of my personal experience with mental illness and recovery is not without some concern regarding its reception by others, I feel it's important I tell my story. This is because I wish to challenge the misunderstanding and stigma that surely surround mental illness. Also, I want to hold out hope to anyone presently struggling in the direction of recovery. I know life has its ups and downs--it does for everyone. But I feel better able to cope and for now, for me, life is good; I hope this article is of help in making this possible for others.     

Role of outpatient psychiatry in therapy of patients with eating disorder]

Eating disorders are common illness but the proportion of those in treatment is still low and their liability to abandon treatment is a constant danger. This is largely due to the pathology: in particular splitting and denial. Thus, the integration of various types of treatment is essential and the process of integration will be efficiently managed if a psychiatric clinic works as a center of the therapeutic network. Formerly, long-term in-patient treatment was regarded as the best choice for treating the patient thoroughly. Nowadays such treatment is not recommended due to the large cost involved in such treatment. Also, removing the patient from a community environment and confining them to an institution over a long period is now regarded as discouraging independence. Thus, the focus of treatment has shifted from in-patient to out-patient treatment. A new model for multi-disciplinary work is now needed because sharing patient information between professionals is more difficult at the outpatient clinic than on an in-patient ward with shared case notes. In order to make the treatment network functional, patients themselves are expected to possess a clear understanding of the illness and its treatment. The application of motivational enhancement theory is useful in this respect. It is the responsibility of psychiatric clinics to encourage the continuous improvement of patient motivation for treatment and to make patients tolerant towards changes in treatment settings.     

Analysis of the rate of convergence of least squares neural network regression estimates in case of measurement errors

Estimation of a regression function from data which consists of an independent and identically distributed sample of the underlying distribution with additional measurement errors in the independent variables is considered. It is allowed that the measurement errors are not independent and have a nonzero mean. It is shown that the rate of convergence of suitably defined least squares neural network estimates applied to this data is similar to the rate of convergence of least squares neural network estimates applied to an independent and identically distributed sample of the underlying distribution as long as the measurement errors are small.     

The pathophysiology of tremor

Tremor is defined as rhythmic oscillatory activity of body parts. Four physiological basic mechanisms for such oscillatory activity have been described: mechanical oscillations; oscillations based on reflexes; oscillations due to central neuronal pacemakers; and oscillations because of disturbed feedforward or feedback loops. New methodological approaches with animal models, positron emission tomography, and mathematical analysis of electromyographic and electroencephalographic signals have provided new insights into the mechanisms underlying specific forms of tremor. Physiological tremor is due to mechanical and central components. Psychogenic tremor is considered to depend on a clonus mechanism and is thus believed to be mediated by reflex mechanisms. Symptomatic palatal tremor is most likely due to rhythmic activity of the inferior olive, and there is much evidence that essential tremor is also generated within the olivocerebellar circuits. Orthostatic tremor is likely to originate in hitherto unidentified brainstem nuclei. Rest tremor of Parkinson's disease is probably generated in the basal ganglia loop, and dystonic tremor may also originate within the basal ganglia. Cerebellar tremor is at least in part caused by a disturbance of the cerebellar feedforward control of voluntary movements, and Holmes' tremor is due to the combination of the mechanisms producing parkinsonian and cerebellar tremor. Neuropathic tremor is believed to be caused by abnormally functioning reflex pathways and a wide variety of causes underlies toxic and drug-induced tremors. The understanding of the pathophysiology of tremor has made significant progress but many hypotheses are not yet based on sufficient data. Modern neurology needs to develop and test such hypotheses, because this is the only way to develop rational medical and surgical therapies.     

Discovery of the "deep personality" and revision of the Kraepelin concept of autonomic mental disease

It is necessary to make a revision of the conception of Kraepelin about schizophrenia and autonomic mental disease. The aim of Kraepelin was to discover an autonomic mental disease like the general paralysis: that was the dementia praecox. It is now impossible to prove this conception. The schizophrenia of Bleuler is characterized by psychic dissociation. Before Bleuler, Moreau de Tours described psychic dissociation not as a mental disease but as a reaction to toxic causes. The new researches about catatonia pointed the exactitude of Moreau de Tours's conception. Behind the apparent dissociation persist a personality that is still living and which it is possible to help and to treat with etiologic treatments and with moral comprehension.     

Management of chronic headache

Chronic headache is an important public health issue since 30p. cent of the French population complains of recurrent headaches. An accurate diagnosis, going beyond approximations, is based on careful questioning and physical examination. Three nosologic entities may be specified: migraine, tension-type headache, and symptomatic headaches which are frequently overvalued. An accurate pathophysiological knowledge is necessary to approach suitable therapeutics. It is also necessary to explain the pathophysiological basis to the patient. It is essential to breath through the frequent nosophobia. When headaches are infrequent, symptomatic treatment is to be favored. Empirical therapy should be explained to obtain good therapeutic observance based on a confidence relationship essential for good patient care.     

Pharmacology of the central control of micturition.

Micturition is the process whereby urine is collected in the bladder until such time as it is convenient to void. The two phases of the cycle are controlled by several reflexes but the act of voiding is usually initiated voluntarily. To date, pharmacological research on the central control of micturition has concentrated on influences of the brain stem and spinal cord, and in particular of the locus coeruleus, the "pontine micturition reflex centre". Studies have shown that spontaneous bladder motility is affected by agents acting upon receptors for acetylcholine, noradrenaline, dopamine, opioids, GABA and glutamate. It is now necessary to extend these studies to conscious animals so that reflex activity is not affected by anaesthesia and the effects of drugs on the collecting and emptying phases can be examined.     

A critical review of clinical applications of topographic mapping of brain potentials

A brief review of several aspects of topographic mapping of brain potentials is presented. Some general factors of importance for the construction of brain maps are considered, namely, how to sample in space and how to deal with the influence of the reference electrode. The issue of what is a representative map is examined for the cases of both steady and dynamic states. Special attention is paid to the methodology of assessing whether a brain map may be considered "normal" or "abnormal" on the basis of multivariate statistical considerations. Besides being used to visualize statistical comparisons between sets of EEG data, brain maps may be used as a first step for a model-based analysis in order to estimate the localization of equivalent dipolar sources of the electrical activity within the brain. The question of whether brain maps may yield added value to multivariate quantitative EEG analysis is examined for the following clinical cases: (1) developmental disorders; (2) space-occupying lesions; (3) epilepsy; (4) cerebrovascular diseases; (5) dementia; and (6) psychiatric diseases. It is concluded that brain mapping may be valuable as a comprehensive and attractive form of data reduction to represent a complex set of multichannel (optimally at least 64) EEG signals, but only if the user is well aware of the pitfalls involved. Brain mapping might supplement quantitative topographic analysis if it can be used as the basis for solving the inverse problem in EEG. More extensive and well-controlled studies are necessary in order to establish the clinical value of complementing a routine EEG examination with brain mapping.