When is the appropriate time for surgical intervention of the herniated lumbar disc in the adolescent?

Symptomatic lumbar disc herniation in the adolescent is uncommon. The appropriate treatment in this particular age group is not clear. We conducted a retrospective review of the medical, surgical, and radiological records of six adolescents with symptomatic lumbar disc herniation who underwent microdiscectomy after failed conservative therapy. The mean follow-up was 13 months. All patients improved quickly and returned to their normal activity levels. We suggest that severe pain resulting from a herniated lumbar disc, even without any neurological deficit, is an indication for microdiscectomy in adolescents so that these patients return to full-time education and normal activities as soon as possible.     

Schizophrenia: Is it time to replace the term?

The attitudes of Japanese psychiatrists toward their patients who suffer from schizophrenia were investigated. We were concerned specifically with whether the psychiatrists inform their patients of the suspected diagnosis. We discuss how the term 'schizophrenia' may influence a psychiatrist's decision to inform his patients of the diagnosis. A self-reported questionnaire was distributed to 150 executive board members of the Japanese Society of Psychiatry and Neurology and analysis of the data obtained from 110 respondents was carried out. The results showed that the concepts that psychiatrists use when they give a diagnosis of schizophrenia vary considerably. Fifty-nine per cent of the respondents informed their patients of a diagnosis of schizophrenia on a case-by-case basis, while 37% informed only the patients' families. A tree analysis showed that the most important predictors for informing the patients of the diagnosis were assumptions about the public image of schizophrenia and a negative impression of the term schizophrenia, translated as 'Seishin Bunretsu Byou' in Japanese. The results revealed that the Japanese term for schizophrenia influences a psychiatrist's decision to inform patients of the diagnosis and that, by changing the term to a less stigmatized one, the disclosure of information about schizophrenia to patients would be promoted.     

Misdiagnosis of thyroid disorders in down syndrome: time to re-examine the myth?

There is a reported association between thyroid disorders and Down syndrome, but is this association based on valid and reliable research evidence? We evaluated thyroid function test results of 110 healthy adults with Down syndrome to determine biochemical thyroid status. Approximately two thirds were biochemically euthyroid when assessed by standard reference ranges for the general population. We believe that there is a need for revalidation of "normal" thyroid function tests parameters when applied to the Down syndrome population and that persons with Down syndrome are possibly being misdiagnosed and inappropriately treated for a nonexistent medical disorder.     

Disclosure of amyloid imaging results to research participants: Has the time come?

Amyloid imaging is becoming an increasingly popular tool in clinical research on Alzheimer's disease. In early studies, questions of whether to disclose amyloid imaging results were largely mooted by the immature state of the science. Lack of clarity as to what constituted a positive scan and what a positive scan meant from a prognostic or diagnostic perspective required investigators to advise research participants that, because their scans could not be meaningfully interpreted in a clinical sense, individual research scan results would not be disclosed. With a focus on the most widely used research tracer, Pittsburgh Compound B (PiB), we consider how advances in amyloid imaging are raising new questions about the appropriateness of withholding research results from study participants. We conclude that, although it remains advisable to withhold amyloid scan results from cognitively normal participants, it is no longer reasonable to uphold policies that unilaterally advise research participants with documented cognitive impairment that their PiB scans are uninterpretable. We outline circumstances that we believe compel investigators to provide research participants with the option of receiving their PiB scan results in a carefully managed fashion. Our findings can potentially be generalized to research involving all validated amyloid tracers.     

Is it time to reassess the BDNF hypothesis of depression?

The brain-derived neurotrophic factor (BDNF) hypothesis of depression postulates that a loss of BDNF is directly involved in the pathophysiology of depression, and that its restoration may underlie the therapeutic efficacy of antidepressant treatment. While this theory has received considerable experimental support, an increasing number of studies have generated evidence which is not only inconsistent, but also directly contradicts the hypothesis. This article provides a critical review of the clinical and preclinical studies which have been responsible for this controversy, outlining pharmacological, behavioural and genetic evidence which demonstrates the contrasting role of BDNF in regulating mood and antidepressant effects throughout the brain. I will also review key studies, both human and animal, which have investigated the association of a BDNF single-nucleotide polymorphism (Val66Met) with depression pathogenesis, and detail the number of inconsistencies which also afflict this novel area of BDNF research. The article will conclude by discussing why now is a critical time to reassess the original BDNF hypothesis of depression, and look towards the formation of new models that can provide a more valid account of the complex relationships between growth factors, mood disorders and their treatment.     

Vertical bias in neglect: a question of time?

Neglect is defined as the failure to attend and to orient to the contralesional side of space. A horizontal bias towards the right visual field is a classical finding in patients who suffered from a right-hemispheric stroke. The vertical dimension of spatial attention orienting has only sparsely been investigated so far. The aim of this study was to investigate the specificity of this vertical bias by means of a search task, which taps a more pronounced top-down attentional component. Eye movements and behavioural search performance were measured in thirteen patients with left-sided neglect after right hemispheric stroke and in thirteen age-matched controls. Concerning behavioural performance, patients found significantly less targets than healthy controls in both the upper and lower left quadrant. However, when targets were located in the lower left quadrant, patients needed more visual fixations (and therefore longer search time) to find them, suggesting a time-dependent vertical bias.     

Does warfarin therapy influence the risk of bladder cancer?

There has been growing interest in studying the biological effects of certain drugs and their potential to reduce the risk of various cancers. One study reported a decrease in the incidence of urogenital cancers in a trial with patients who received warfarin for treatment of venous thromboembolism, but a limitation to this study of urogenital cancers was the very small number of bladder cancer cases that developed following warfarin therapy. The objective of the present study is to measure the association between warfarin use and bladder cancer. A total of 330 cases with bladder cancer were identified at the James A. Haley Veterans' Administration (VA) Hospital in Tampa, Florida, using a combination of computerized pathology records and inpatient and outpatient diagnoses. Controls were randomly selected from the VA computerized administrative database and 1293 controls were included for analysis. Unconditional logistic regression analysis was performed to assess the risk of bladder cancer after adjusting for age, gender, and cigarette smoking. Among warfarin users, although there was a 27% elevation in risk, it did not differ significantly from nonusers (OR = 1.27, 95% CI = 0.85, 1.89). No duration-response relationship was observed between anticoagulant use and risk of bladder cancer. The results suggest that warfarin does not protect against bladder cancer, at least in male smokers, the highest risk population for bladder cancer.     

Does a preference for fatty foods prior to commencing treatment with the ketogenic diet predict the efficacy of this diet?

The ketogenic diet can be effective in children who suffer from drug-resistant epilepsy. However, it is still hard to predict how large an effect this diet will have for an individual child. Previous data suggests a high-fat food preference is more likely in those with epilepsy, as assessed by in-person forced-choice design. The aim of this study is to examine whether a partiality to fatty foods prior to commencing the ketogenic diet can be used as a predictive factor for the efficacy of this diet in children with drug-resistant epilepsy.Data from 43 children aged between 2 and 19 years was used in this retrospective, non-controlled, non-randomised, open study. All children had followed the ketogenic diet for a period of 3 months or more. Before commencing the diet, a food record was collected for each child to determine the percentage of daily energy-intake accounted for by fats. Parents of the participants completed a questionnaire to measure fat-preference in the pre-diet period and received a score to objectify the efficacy of the treatment.The raw scores on the food record and on the questionnaire were divided into subgroups. Subsequently Kendall's tau-b was calculated for the correlation between each combination of variables. A non-significant correlation was found for the relationship between the food record and the questionnaire (p = .939), the relationship between the food record and the efficacy of the treatment (p = .827) and the relationship between the questionnaire and the efficacy of the treatment (p = .539). This means treatment efficacy cannot be predicted by the child's food preference.     

Worsening of depressive symptoms prior to randomization in clinical trials: a possible screen for placebo responders?

A common practice in depression trials is to exclude patients whose depressive symptoms improve between Screen and Baseline evaluations under the assumption that they are more likely to respond to placebo. The present study investigated this contention by examining the relationship between pre-randomization changes in Hamilton depression rating scale (HAMD) scores to post-randomization placebo response and drug-placebo separation. Four randomized, double-blind, placebo-controlled trials (active medication=fluoxetine or paroxetine) were conducted in outpatients with Major Depressive Disorder using a novel design in which a depressive severity inclusion criterion (HAMD >/= 22) was utilized only at Screen. Patients with no change or minimal (1 point) improvement on the HAMD between Screen and Baseline had the lowest placebo response and the best drug-placebo separation. Patients with pre-randomization improvement of 2 points or greater had moderately higher placebo response and poorer drug-placebo separation. Patients who worsened between Screen and Baseline showed the highest placebo response and the poorest drug-placebo separation. There were no obvious differences in demographic variables between the groups which could account for the findings. In our original analyses 3/4 studies failed to show significant drug-placebo separation. When only patients with no change or pre-randomization improvement of 1 point were used in the analyses, 3/4 studies showed significant drug-placebo separation while the other study approached significance, p < 0.07. These results suggest that pre-randomization changes in HAMD scores may predict post-randomization placebo response and drug-placebo separation. Further, pre-randomization increases in HAMD scores (i.e., worsening) may be the best predictor of heightened placebo responding and poor drug placebo separation.