Minimalinvasive Ablationsverfahren in der Epilepsiechirurgie

Clinical Epileptology -     

Can low-intensity tACS genuinely entrain neural activity in vivo?

Transcranial alternating current stimulation (tACS) was introduced about a decade ago as a non-invasive brain stimulation method to modulate neural oscillations in a relatively safe manner in humans. However, the possibility to induce genuine neural entrainment with low current intensities has been questioned. In a recent study, Johnson and colleagues provide direct evidence for the efficacy of low-intensity tACS to induce neural entrainment in awake monkeys. These findings have important translational implications for human non-invasive neuromodulation research.     

Early-Onset Oppositional Defiant Disorder: What Factors Predict Its Course?

Although the early onset of Oppositional Defiant Disorder (ODD) is associated with an elevated risk of later psychopathology (including but not limited to conduct disorder and antisocial personality disorder), little is known about the factors influencing the course of this disorder in early life. In this article we first review data and theory from four conceptually-distinct domains of risk factors for disruptive disorders (child characteristics reflecting biologic vulnerabilities, parent-child attachment, parenting practices, and family adversity). Then we describe an empirical study that examined the power of these four domains (representing 10 specific risk factors) to predict the prognosis of clinic-referred, preschool boys with ODD; risk factors were assessed when these youngsters were first evaluated in the clinic and outcomes were measured 2 years later. The primary goal was to determine the unique importance of risk factors in the context of others examined simultaneously, a strategy that few previous studies have used. We found that the four-factor risk model predicted significant variance in mother's reports of externalizing (disruptive) behavior problems at the 2-year follow-up; however, the model did not predict teacher externalizing scores or clinicians' assessments of Diagnostic and Statistical Manual (DSM) disorders, as hypothesized. Analyses of specific factors within domains suggested that three were most consistently related to the negative outcomes of ODD boys: greater use of physical discipline by parents, greater life stress for families, and a greater number of pre- and perinatal complications. Nearly a third of the variance in mothers' reports of internalizing (inhibited) problems was attributable to two of these risk factors (life events stress and birth history) and to a third factor, delayed child development.     

What happens to applicants for psychotherapy?

Five hundred consecutive applicants for psychotherapy at the Postgraduate Center for Mental Health were followed up. Of the applicants, 51.8% entered, 37.2% withdrew before treatment and 11% were rejected by the Center. Of the withdrawers, 37.7% reported having entered, and another 9.2% having applied for treatment elsewhere. Only 8% of dropouts from individual therapy during the first six sessions had entered, and no one else had applied for treatment elsewhere. This difference was found to be significant beyond the. 01 level. A very significant difference was found between terminators before the eighth and those after the seventeenth session in terms of frequency of sessions. Only 8% of the former, but 100% of the latter were seen twice a week.This work was supported by National Institute of Mental Health grant 1-R11 MH1090-1.     

What Evolution Intended? Reply to Wakefield

Wakefield doesn't mind my focus on parallels between addiction and love. But love can fall outside the bounds of what evolution intended. So, he claims, comparing addiction with love does not preclude a naturally defined "disorder." I counter with the argument that evolution handed us such highly general response systems, the bounds of normality cannot be defined.     

What makes a difference to patients?

Abstract

To make a difference to patients who increasingly suffer multiple chronic conditions, in a healthcare system that is capable of providing excellent care but is often ineffective and at cross-purposes in its application, means being prepared to take a different approach not only to the delivery of patient care, but to the education of physicians and other healthcare professionals. The model we must now practice and teach is one that emphasizes collaboration and prevention, quality and efficiency. Changes in practice recommended by the 2001 US Institute of Medicine report are being implemented system-wide, following the enactment of the US Patient Protection and Affordable Care Act. This paper discusses the evolving needs of patients with chronic psychiatric illness, and the psychiatrist's role in a rapidly changing healthcare landscape as a care provider, an interdisciplinary role model, and educator. In an aging population in which multi-morbidity is the norm, episodic, crisis-driven care is prohibitively expensive and does not serve patients well. Yet we still teach that model of care. The medications we prescribe for psychiatric illness, particularly antipsychotics, can cause and/or aggravate some of the commonest chronic medical illnesses; psychiatric educators must address the management of these complications. The management of chronic psychiatric illness in multi-morbid patients demands that we practice and teach a ‘whole patient’ approach to care, preferably delivered as part of a patient-centred team. The Affordable Care Act has mandated and created opportunities for new models designed to facilitate this, and a paradigm shift is needed in medical education. Clinicians must become adept at identifying underlying and contributing factors and collaborating with the patient, other providers, and the patient's family and significant others. Psychiatric formulation and patient care rely on these principles; we must now teach their application to other specialties, disciplines and professions.     

Asperger's syndrome: What to consider?

Asperger's syndrome is a neurodevelopmental disorder which is part of the large family of autism spectrum disorders. People with Asperger's syndrome have difficulties in social interactions, verbal and non-verbal communication, and may display behavioural oddities, with stereotypies and limited interests. They show no language delay and their cognitive development is not marked by an overall delay but by specific impairments in certain areas such as the executive functions. The clinical presentations are very heterogeneous, varying according to age and psychiatric comorbidities. Screening, diagnosis and specialized treatment are not made any easier by the diversity of the clinical manifestations. Asperger's syndrome is often diagnosed belatedly, at 11 years of age on average and even in adulthood in some cases. This late diagnosis has a significant impact on the risks of depression and a poor quality of life. However, in adulthood or in adolescence, certain situations, personality traits and cognitive profiles or certain comorbidities should suggest the hypothesis of an Asperger-type autism spectrum disorder. We propose here a review of the clinical situations at different ages of life that could help with the screening and the referral of patients to specialized clinicians for diagnosis and appropriate treatment.     

What real outcomes matter to caregivers?

Two surveys of caregivers of people with dementia were conducted in the U.K. and Poland. Among 64 U.K. carers, cognition, early diagnosis and general practitioner support were of particular concern to those caring for people with early dementia, while former carers were more concerned with pain, comfort and palliative issues. There was very strong support for better workforce training. In Poland, restoration of health and more time off from caring were the most desired outcomes.     

‘What becomes of demented patients referred to a psychogeriatric unit?’ An approach to audit

A 1-year follow-up study was undertaken of a random sample of 40 elderly patients living at home given a diagnosis of "dementia" after referral to the Psychogeriatric Department at St Charles' Hospital, London, W10. Eighteen (45%) patients were admitted to institutional care. There was an association between physical disability and institutionalization. A similar tendency was observed for social disturbance and hospital admission. The 1-year survival rate for the sample was 82.5%. All the seven patients who died were moderately/severely demented. Twenty-three patients (55%) had informal key carers. Half of these showed considerable stress according to the General Health Questionnaire and the Strain Scale scores. All the recommendations made by the psychogeriatric team were carried out without much delay.     

Migraine and Stroke: What’s the Link? What to Do?

Migraine and stroke are common, disabling neurologic disorders, with a high socioeconomic burden. A link between them has been proposed years ago, and various theories have been proposed to explain this bidirectional relation. However, the precise causes remain unclear. We briefly summarize existing hypotheses of this correlation seeking for recommendations for stroke prevention in migraineurs, if any exist. Among the strongest suggested theories of migraine–stroke association are cortical spreading depression, endovascular dysfunction, vasoconstriction, neurogenic inflammation, hypercoagulability, increased prevalence of vascular risk factors, shared genetic defects, cervical artery dissection, and patent foramen ovale. There is no evidence that any preventive therapy in migraineurs should be used to decrease stroke risk, even in most predisposed subset of patients. However, a woman with migraine with aura should be encouraged to cease smoking and avoid taking oral contraceptives with high estrogen doses. We need further investigation to better understand the complexity of migraine–stroke association and to make firm recommendations for the future.     

Does Analgesic Overuse Contribute to Chronic Post-traumatic Headaches in Adolescent Concussion Patients?

BackgroundThe causes of persistent headache following concussion are poorly understood. The objective of this study is to explore analgesic overuse as a potential cause of chronic post-traumatic headache among adolescents referred to a headache clinic following concussion.MethodsA retrospective chart review was conducted of all adolescent concussion patients referred to our pediatric headache clinic over the 16-month period between August 1, 2011, and November 30, 2012. Those patients with chronic post-traumatic headaches of 3-12 months' duration who also met International Headache Society criteria for probable medication-overuse headache were identified. Demographic data, concussion symptoms, and headache features were characterized from the initial evaluation and from follow-up visits.ResultsOf 104 adolescent concussion patients referred during the study period, 77 had chronic post-traumatic headache of 3-12 months' duration. Fifty-four of 77 (70.1%) met criteria for probable medication-overuse headache. Only simple analgesics were overused. Thirty-seven patients (68.5%) had resolution of headaches or improvements to preconcussion headache patterns after discontinuing analgesics; seven (13%) had no change in headaches or worsening of headaches after discontinuing analgesics and 10 (18.5%) did not discontinue analgesics or were lost to follow-up.ConclusionExcessive use of analgesics postconcussion may contribute to chronic post-traumatic headaches in some adolescents. Management of patients with chronic post-traumatic headache should include analgesic detoxification when medication overuse is suspected.