Pediatric stroke: what do we know and what do we need to know?

Stroke is a heterogeneous disorder and an important cause of mortality and chronic morbidity in children. Estimates of international incidence rates for childhood stroke have varied widely. Arterial ischemic stroke is reported to be more common than hemorrhagic stroke in children. The clinical presentation of stroke in children differs according to the child's age and stroke type and location. Several risk factors for ischemic and hemorrhagic stroke in children have been reported and include cardiac disorders, blood disorders, vasculopathies, viral infections, and arteriovenous malformations. Current treatment recommendations for stroke in children are based on small nonrandomized trials, adult stroke studies, case series, or consensus or individual expert opinion. Over half of children with stroke will develop lifelong cognitive or motor disability, and up to a third will have a recurrent stroke. International studies have provided important information on stroke in children, but major gaps in our knowledge of the disorder still exist. Currently, there is a need for prospective cohort studies in diverse populations, which utilize a consensus pediatric stroke classification system and a standard evaluation of risk factors and outcome, so that treatment and prevention strategies can be developed.     

Brain temperature: what do we know?

This review article presents a summary of recent efforts to understand brain temperature and its regulation under different conditions. Brain temperature has a crucial influence on brain processes. Its regulation is the outcome of the balance of core and arterial blood temperatures, cerebral blood flow, brain metabolism, functional conditions, and external temperature. However, the relationship between these factors is not fully understood and several uncertainties remain. There are no satisfactory normative data on temperatures throughout the brain, but new technologies promise to fill this gap. Brain temperature changes with brain functional activation and under pathological conditions in ways that are not understood. A full understanding of brain temperature control is mandatory to optimize attempts at brain cooling during clinical conditions such as stroke and head injury.     

Recovery-based practice: do we know what we mean or mean what we know?

The concept of recovery is now widely promoted as the guiding principle for the provision of mental health services in Australia and overseas. While there is increasing pressure on service providers to ensure that services are recovery oriented, the way in which recovery-based practice is operationalized at the coalface presents a number of challenges. These are discussed in the context of five key questions that address (i) the appropriateness of recovery as a focus for service delivery, (ii) the distinction between recovery as a process and an outcome, (iii) the assessment of recovery initiatives, (iv) the alignment of recovery with current service delivery models, and (v) the risks associated with recovery-based practice. It is argued that these questions provide a framework for a debate that must extend beyond patients and providers of mental health services to the broader public, whose attitudes will ultimately determine the possibilities and limits of recovery-oriented practice.     

Sleep deprivation in depression: what do we know, where do we go?

Manipulations of the sleep-wake cycle, whether of duration (total or partial sleep deprivation [SD]) or timing (partial SD, phase advance), have profound and rapid effects on depressed mood in 60% of all diagnostic subgroups of affective disorders. Relapse after recovery sleep is less when patients are receiving medication; it may be prevented by co-administration of lithium, pindolol, serotonergic antidepressants, bright light, or a subsequent phase advance procedure. Diurnal and day-to-day mood variability predict both short-term response to SD and long-term response to antidepressant drug treatment. These mood patterns can be understood in terms of a "two-process model of mood regulation" based on the model well established for sleep regulation: the interaction of circadian and homeostatic processes. The therapeutic effect of SD is postulated to be linked to changes in disturbed circadian- and sleep-wake-dependent phase relationships and concomitant increase of slow-wave-sleep pressure; additionally, SD-induced sleepiness may counteract the hyperarousal state in depression. This model has the advantage of providing a comprehensive theoretical framework and stringent protocols ("constant routine," "forced desynchrony") to dissect out specific disturbances. Many aspects tie in with current serotonergic receptor hypotheses of SD action. A treatment inducing euthymia in severely depressed patients within hours is an important therapeutic option that has come of age for clinical use.     

Text level reading comprehension in aphasia: What do we know about therapy and what do we need to know?

Background: Reading comprehension difficulties are a common feature of aphasia, affecting the understanding of single words, sentences, paragraphs and extended text. Whilst there have been studies investigating treatment for single word reading, there are a limited number of studies of treatment methods targeting the reading of paragraphs and connected text.

Aims: This paper will describe a series of single case studies, each investigating the effectiveness of a different therapy approach for paragraph level reading comprehension. The studies raise a number of issues regarding the assessment of reading, choice of therapy and measurement of outcome; these will be discussed in relation to the studies and the wider evidence base.

Methods & Procedures: Four people with aphasia were involved in the studies. Participants presented with reading difficulties alongside other language difficulties. Each study involved a single case study, multiple baseline with control task design. Detailed assessment of reading comprehension was completed pre-therapy, post-therapy and at follow-up, approximately 2–4 weeks post-therapy. Participants were also asked about their pre-morbid reading abilities and preferences, their reading difficulties and their views about therapy and its impact.

Outcomes & Results: All participants showed some improvement in the accuracy of reading comprehension but there was extensive variability in the significance of gains, when gains were seen and on which assessments. Post-therapy, three of the four participants read the assessment passages and answered the questions more quickly. All participants reported some positive change in their reading, either in reading ability, reading behaviour or feelings about reading, but again individual variation was evident in the extent and type of change perceived.

Conclusions: These studies raise a number of important issues regarding the assessment of reading, therapy choice and measuring the outcome of therapy. These issues are discussed in relation to current literature, with an aim of informing future research investigating the assessment of, and therapy for, reading comprehension difficulties in people with aphasia. Reading is fundamental to everyday activities and developing the evidence base is of crucial importance in supporting people with aphasia to maximise their reading ability.     

Predicting and preventing suicide: do we know enough to do either?

In population studies, many risk factors are associated with suicide completion. Yet we cannot accurately predict whether any individual patient will die by suicide. Completers are a distinct population from attempters and do not necessarily present for treatment by mental health professionals. Research on suicide prevention has yielded some promising findings but has not shown that interventions produce definitive results. The strongest evidence for successful prevention derives from reducing access to means. A population-based strategy may be more effective than a high-risk strategy focusing on patients with suicidal ideas or attempts. Much more research is needed before developing effective suicide prevention programs.     

Epilepsy stigma: what do we know and where next?

Stigma is a major issue for people who develop epilepsy. Reducing stigma is a major focus of activity for the epilepsy patient support groups globally. In this paper, we introduce some key ideas and debates about the nature of and drivers for the stigma of epilepsy, including recent arguments about the need to frame analyses of the nature of epilepsy stigma within sociological debates about conflict and power. We then consider the role of the legislative process for redressing power imbalances that promote or maintain epilepsy stigma; and the value of tailored educational campaigns and programmes directed at stigma reduction. Finally, we consider the nature of ‘difference’ as experienced by people with epilepsy and how that difference translates into stigma; and provide evidence from a specific targeted intervention to combat epilepsy stigma that its reduction is an achievable goal.     

Empathy. We know what we mean, but what do we measure?

In recent years, quantitative researches on the empathic process in psychotherapy have resulted in definite recommendations for the technique of psychotherapy and the training of psychotherapists. What is not always observed, however, is that the methods employed for studying empathy have been based on brief segments of patient-therapist interaction in which judgments of empathy do not depend on hearing the patient's communications, and are in several ways discordant with what is meant by empathy according to clinical theory. Evidence suggests that it is the rater's impression of the "goodness of psychotherapy" rather than empathy that is being captured by these methods.     

The genetic basis of migraine: how much do we know?

Migraine with and without aura is thought to be genetically complex with aggregation in families due to a combination of environmental and genetic tendencies. Twin studies are most important in establishing the multifactorial nature of migraine with heritability approaching 50%. Familial hemiplegic migraine (FHM) on the other hand is an autosomal dominant, highly penetrant, though rare form of migraine with strong genetic tendency. Fifty percent of families with FHM are linked to chromosome 19p13 and mutations demonstrated for some in a brain expressed calcium channel alpha 1A subunit, CACNL1A4. Other FHM loci have been identified on chromosome 1q and further genetic heterogeneity is likely. The exact role of the mutated calcium channel in the pathway leading to hemiplegic migraine is yet to be established. Changes in the electrophysiologic properties of the mutated forms of the CACNL1A4 calcium channel expressed in heterologous systems help establish the functional significance of the mutations and suggest that chromosome 19p-linked FHM, an episodic disorder, represents a CNS channelopathy. Additional candidate genes causative for migraine might include other calcium channel subunits and related proteins important for neuronal membrane stability. Delineating the cascade of biochemical events leading to hemiplegic migraine will serve as a model for understanding the pathophysiology of more common forms of migraine. The evidence suggesting that some families of migraine with and without aura might also be related to the chromosome 19p locus, chromosome Xq28 locus, or DRD2 receptor polymorphisms is reviewed.     

Group therapy for substance use disorders: what do we know?

Although group therapy is the most prevalent treatment modality for substance use disorders, an up-to-date review of treatment outcome literature does not exist. A search of the literature yielded 24 treatment outcome studies comparing group therapy to other treatment conditions. These studies fell into one of six research design categories: (1) group therapy versus no group therapy; (2) group therapy versus individual therapy; (3) group therapy plus individual therapy versus group therapy alone; (4) group therapy plus individual therapy versus individual therapy alone; (5) group therapy versus another group therapy with different content or theoretical orientation; and (6) more group therapy versus less group therapy. In general, treatment outcome studies did not demonstrate differences between group and individual modalities, and no single type of group therapy reliably demonstrated greater efficacy than others. Unique methodological and logistical hurdles encountered in research on group therapy for substance use disorders, as well as considerations for future research, are also discussed.     

ECT in the Asia Pacific region: what do we know?

OBJECTIVE: To review and describe the practice of ECT in the Asia Pacific region in the year 2000. METHOD: A survey of 34 defined countries within the Asia Pacific region was made prior to the 1st Asia Pacific ECT Conference held in Melbourne, Australia, 2001. RESULTS: Contact addresses for 23 of 34 countries (70%) were found with responses from 12 different countries (35%). Individual responses were received from less than 1% of the total mail out for the conference. The percentage of inpatients who received ECT was consistently less than or equal to 9%, except for Nepal where it was 25.6%. Except for Kiribati and the Solomon Islands, all devices delivered brief pulse, square wave currents. All of the 12 countries surveyed used anesthesia, preferred bilateral electrode placement and reported a response rate of at least 86%. Adverse events were uncommon, memory being the most commonly reported side effect. Community attitudes were generally negative. CONCLUSION: Despite the difficulties in attempting to generalize about this huge and diverse region, a number of seemingly universal findings appeared in accord with the world literature. These included the widespread use of ECT, its effectiveness and its relative safety despite equally widespread community reluctance.     

Psychopharmacologic interventions in nursing homes: what do we know and where should we go?

Psychiatric symptoms are common among individuals who live in nursing homes, with prevalence rates ranging from 51 percent to 94 percent. Accordingly, psychotropic medications are widely prescribed in this setting and are the subject of considerable debate and regulation. Current regulations arose from public and governmental concerns that psychiatric medications were being prescribed inappropriately to frail patients. Concern has also been raised about the absence of evidence on which to base prescribing decisions. Nursing homes are slowly being recognized as complex health care settings that warrant considerable research attention. This article explores the origins of the regulation of the use of psychotropic drugs in nursing homes, reviews controlled trials of these drugs in nursing homes, examines the role of these agents in adverse drug events experienced by nursing home residents, and proposes policy and research areas that merit consideration.