芦山地震后6年雅安市城市老年人抑郁症状检出情况及影响因素

目的 了解芦山地震后6年雅安市城市老年人抑郁症状检出率及特点,为灾难性事件后老年人群心理干预提供参考。方法 采取多阶段分层整群随机抽样方法,于2019年3月-4月选取雅安市城市老年人（年龄≥60岁）885名为研究对象,采用自制一般信息调查表收集老年人一般人口学资料、健康状况以及受灾情况,采用老年抑郁量表（GDS-30）评估其抑郁症状。采用单因素和多因素Logistic回归分析城市老年人抑郁症状的影响因素。结果 共回收有效问卷783份,有效问卷回收率为88.47%,检出存在抑郁症状者161例（20.56%）;不同性别、年龄、婚姻状况、家庭关系、家庭人均月收入、身体锻炼情况、健康状况、生活自理情况、睡眠状况、受灾程度的城市老年人抑郁症状检出率比较差异均有统计学意义（P<0.05或0.01）。Logistic回归分析显示,女性（OR=1.552,P=0.040）、家庭人均月收入2000~3000元（OR=6.982,P<0.01）、家庭人均月收入≤2000元（OR=6.857,P<0.01）、无身体锻炼情况（OR=1.693,P<0.01）、生活部分自理（OR=3.838,P<0.01）、生活不能自理（OR=8.547,P<0.01）、多病可治愈（OR=4.892,P<0.01）、久病难治（OR=5.657,P=0.031）的老年人出现抑郁症状的风险较高;相比于离异和丧偶者,已婚老年人出现抑郁症状的风险更低（OR=0.063,P<0.01）。结论 芦山地震后6年雅安市城市老年人抑郁症状检出率较高,其中女性、家庭人均月收入低、无身体锻炼情况、生活不能完全自理、健康状况差为出现抑郁症状的危险因素,已婚为保护因素。     

高职大专学生睡眠状况及影响因素

背景 睡眠障碍对人群身心健康及社会经济发展均会产生不良影响,高职大专学生承受着学习、就业和家庭经济状况等方面的压力,其睡眠质量可能会受到一定程度的影响。目的 探讨高职大专学生睡眠状况及影响因素,为改善高职大专学生睡眠状况提供参考。方法 于2022年1月-2月,采用分层随机抽样,选取成都市温江区5所高职大专院校的3 300名学生为研究对象。使用失眠严重程度指数量表（ISI）、患者健康问卷抑郁量表（PHQ-9）、广泛性焦虑障碍量表（GAD-7）进行评定。采用Pearson相关分析考查ISI评分与PHQ-9评分和GAD-7评分之间的相关性;采用Logistic回归分析考查失眠症状的影响因素。结果 检出2 497名（81.90%）高职大专学生存在失眠症状。不同性别、家庭经济状况、是否独生子女、学习或就业带来的心理压力、平均每天上网时长、体育锻炼以及是否有焦虑症状或抑郁症状的高职大专学生失眠症状检出率差异均有统计学意义（χ²=21.032、22.172、8.983、75.939、36.781、32.350、54.512、86.561,P<0.01或0.05）。高职大专学生ISI评分与GAD-7评分和PHQ-9评分均呈正相关（r=0.620、0.714,P均<0.01）,GAD-7评分与PHQ-9评分呈正相关（r=0.824,P<0.01）。性别、家庭经济状况、学习或就业带来的心理压力、平均每天上网时长、体育锻炼是否达标以及是否有抑郁症状可预测高职大专学生的失眠症状（P<0.01或0.05）。结论 女性、家庭经济状况一般和很差、学习或就业带来的心理压力中等或较大以及平均每天上网时长2~5 h、5~7 h、>7 h及体育锻炼未达标、存在抑郁症状是高职大专学生出现失眠症状的危险因素。     

普遍信任在女性青少年抑郁症患者依恋与抑郁之间的中介作用

背景 女性青少年比男性青少年的抑郁症患病率更高且症状更重。青少年的普遍信任水平与抑郁症状严重程度相关,且依恋与普遍信任水平相关。故本研究基于普遍信任在依恋与抑郁之间的中介作用,探寻女性青少年抑郁症的发病机制。目的 探讨女性青少年抑郁症患者普遍信任在父亲、母亲、同伴依恋与抑郁之间的中介作用,为改善女性青少年抑郁症患者的抑郁症状提供参考。方法 纳入2022年3月-10月在杭州市第七人民医院门诊及住院部治疗的符合《国际疾病分类（第10版）》（ICD-10）抑郁症诊断标准的女性青少年患者73例,采用修订版青少年依恋问卷（IPPA-R）、普遍信任量表（IGTS）和儿童抑郁量表（CDI）进行调查。使用Pearson相关分析探讨各量表评分的相关性。使用Bootstrap法检验普遍信任在依恋与抑郁之间的中介作用。结果 ①女性青少年抑郁症患者CDI评分与IPPA-R中的父亲、母亲、同伴依恋三个分量表评分均呈负相关（r=-0.463、-0.459、-0.447,P均<0.01）;IGTS评分与IPPA-R中的父亲、母亲、同伴依恋三个分量表评分均呈正相关（r=0.372、0.318、0.395,P均<0.01）;IGTS评分与CDI评分呈负相关（r=-0.531,P<0.01）。②中介效应检验显示,女性青少年抑郁症患者父亲、母亲、同伴依恋与抑郁水平的直接效应显著（效应值=-0.138、-0.136、-0.107,95% CI：-0.236~-0.039、-0.242~-0.029、-0.203~-0.012）。③普遍信任在父亲、母亲、同伴依恋与抑郁水平之间的中介效应显著（效应值=-0.069、-0.066、-0.071;95% CI：-0.127~-0.021、-0.137~-0.010、-0.145~-0.018）。结论 父亲、母亲、同伴依恋可以直接影响女性青少年抑郁症患者的抑郁水平,也可以通过普遍信任间接影响抑郁水平。     

新冠肺炎疫情下浏阳市精神疾病患者家属焦虑抑郁情况及影响因素

目的 了解新冠肺炎疫情期间精神疾病患者家属焦虑、抑郁情况及影响因素。方法 采用横断面研究,通过立意抽样和分层抽样的方法,选取2020年3月18日-28日浏阳市精神病医院门诊患者家属116名和住院患者家属111名。采用焦虑自评量表（SAS）、抑郁自评量表（SDS）和自行设计的一般资料问卷进行调查,并对数据进行单因素和多因素Logistic回归分析。结果 共回收问卷239份,其中有效问卷227份,有效问卷回收率为94.98%。检出存在焦虑症状者29人,焦虑检出率为12.78%;检出存在抑郁症状者40人,抑郁检出率为17.62%。Logistic回归分析显示,家属年龄≥60岁（OR=4.454,P=0.041）、睡眠质量评价为中等及以下（OR=17.922、153.728,P<0.01）、患者疫情期间居家休息（OR=5.597,P=0.004）是家属存在焦虑症状的危险因素;睡眠质量评价为中等及以下（OR=7.806、15.105,P<0.01）、受教育程度低（OR=0.137、0.205,P<0.05）、患者疫情期间居家休息（OR=2.868,P=0.022）是家属存在抑郁症状的危险因素。结论 新冠肺炎疫情期间精神疾病患者家属存在一定程度的焦虑、抑郁情绪。其中,年龄≥60岁、睡眠质量不佳、患者居家休息、受教育程度低是家属存在焦虑和抑郁的危险因素。     

网络认知行为治疗对癌症患者心理痛苦、抑郁、焦虑和生活质量影响的Meta分析

背景 网络认知行为治疗（ICBT）越来越多地应用于缓解癌症患者的焦虑抑郁情绪,但目前尚无ICBT对癌症患者焦虑、抑郁、心理痛苦以及生活质量影响的荟萃分析。目的 运用系统评价的方法,探讨ICBT对缓解癌症患者心理痛苦、抑郁、焦虑症状以及提高生活质量的效果。方法 于2022年3月28日,以PubMed、PsycINFO、Embase、Cochrane Library、Web of Science、中国知网、维普、万方、中国生物医学文献数据库为数据源,系统收集关于癌症患者心理痛苦、抑郁、焦虑、生活质量、且以ICBT为治疗手段的随机对照试验（RCT）。评价纳入文献的偏倚风险后,采用Stata 17.0进行Meta分析。结果 共纳入12项RCT,包括1 686例患者。Meta分析结果显示,与对照组接受的干预措施相比,ICBT有助于缓解癌症患者的心理痛苦（SMD=-0.547,95% CI：-1.090~-0.145,P<0.01）,但对抑郁（SMD=-0.652,95% CI：-1.734~0.002,P=0.051）、焦虑（SMD=-1.045,95% CI：-3.656~0.101,P=0.088）以及生活质量（SMD=0.234,95% CI：-0.064~0.449,P=0.112）的改善效果不明显。ICBT组脱落率高于对照组（OR=1.795,95% CI：1.358~2.374,P<0.01）。结论 ICBT对癌症患者的心理痛苦有一定的缓解作用,但对抑郁和焦虑症状以及生活质量的改善不明显。     

青少年抑郁障碍患者与双相情感障碍患者睡眠特征及其对自杀风险的影响

目的 比较青少年抑郁障碍患者和双相情感障碍患者睡眠结构特征的差异,探讨睡眠指标等因素对患者自杀风险的影响。方法 回顾性查阅广州医科大学附属脑科医院2019年1月1日-2021年6月30日符合《国际疾病分类（第10版）》（ICD-10）诊断标准的抑郁障碍（n=97）和双相情感障碍（n=52）住院青少年患者病历资料,收集患者的年龄、性别、体质量指数（BMI）、精神科诊断、自杀风险评估量表（NGASR）评分及多导睡眠监测（PSG）结果。根据NGASR评分结果,将患者分为两组：0~5分为自杀低风险组（n=32）,>5分为自杀高风险组（n=117）。以既往文献中80例正常青少年的PSG数据作为对照组资料。建立多元线性回归模型探讨青少年情感障碍患者自杀风险的影响因素。结果 自杀高风险组睡眠效率和N2期睡眠占比均低于自杀低风险组（Z=-2.138、-2.520,P均<0.05）。抑郁组总睡眠时间、N2期睡眠时间以及REM期睡眠时间均少于双相组（t=-2.822、-3.087、-2.277,P<0.05或0.01）;抑郁组和双相组REM期睡眠占比均低于对照组（t=-2.369、-2.069,P均<0.05）。线性回归分析显示,青少年情感障碍患者自杀风险的影响因素包括N1期睡眠时间（β=0.019,P<0.05）、性别（男性vs.女性,β=-4.051,P<0.01）以及诊断（双相情感障碍vs.抑郁障碍,β=-1.429,P<0.05）。结论 与青少年双相情感障碍患者相比,青少年抑郁障碍患者存在睡眠连续性差、浅睡眠更少的特点。N1期睡眠时间、女性以及诊断为抑郁障碍是青少年情感障碍患者自杀的影响因素。     

老年白内障患者合并抑郁状况及其自我感受负担的影响

背景 伴抑郁症状的老年白内障患者自我感受负担较重,术后视觉相关生活质量较无抑郁症状的患者更差,家庭负担更重。既往研究多认为家庭关系、视力等是导致老年白内障患者出现抑郁症状的主要因素,自我感受、合并疾病等对老年白内障患者心理状态的影响研究有限。目的 探讨老年白内障患者抑郁症状与自我感受负担和术后视觉相关生活质量的关系,分析患者抑郁症状的危险因素,对其进行针对性的心理干预提供参考。方法 连续纳入2020年7月1日—2022年12月31日在江苏省人民医院（南京医科大学第一附属医院）住院治疗的老年白内障患者104例,采用自编调查问卷收集患者基本资料,采用患者健康问卷抑郁量表（PHQ-9）、自我感受负担量表（SPBS）、25项美国国家眼科研究所视功能问卷（NEI-VFQ-25）评定患者抑郁症状、自我感受负担以及术后视觉相关生活质量水平。采用Pearson相关分析考查伴抑郁症状的老年白内障患者PHQ-9、SPBS、NEI-VFQ-25评分的相关性,采用Logistic回归分析老年白内障患者抑郁症状的影响因素。结果 共100例老年白内障患者完成有效问卷调查,检出31例（31.00%）患者存在抑郁症状。抑郁组SPBS评分高于无抑郁组（t=11.062,P<0.01）,NEI-VFQ-25评分低于无抑郁组（t=-5.235,P<0.01）。Pearson相关分析结果显示,伴抑郁症状的老年白内障患者PHQ-9评分与SPBS评分呈正相关（r=0.485,P<0.01）,与NEI-VFQ-25评分呈负相关（r=-0.440,P<0.01）。合并糖尿病（OR=1.441,P<0.01）、合并骨关节炎（OR=1.324,P<0.05）和高SPBS评分（OR=1.340,P<0.05）是老年白内障患者出现抑郁症状的危险因素。结论 老年白内障患者抑郁症状检出率较高;伴抑郁症状的老年白内障患者术后视觉相关生活质量更低;合并糖尿病、骨关节炎以及自我感受负担较重是老年白内障患者出现抑郁症状的危险因素。     

抑郁症患者D型人格与述情障碍的相关性

目的 探索抑郁症患者述情障碍与D型人格的关系,为丰富抑郁症相关的心理理论提供参考。方法 于2020年5月-8月选取四川省人民医院心身医学科住院部中符合《精神障碍诊断与统计手册（第5版）》（DSM-5）抑郁症诊断标准的患者（n=100）为研究对象,采用自编一般人口学问卷、D型人格量表（DS-14）、多伦多述情障碍量表（TAS-20）及患者健康问卷抑郁量表（PHQ-9）调查患者基本信息、D型人格、述情障碍及抑郁症状情况。采用Spearman相关分析检验各量表评分间的相关性。结果 共82例抑郁症患者完成调查,其中75例（91.46%）具有D型人格,50例（60.98%）具有述情障碍;患者TAS-20、DS-14总评分及PHQ-9评分两两之间均呈正相关（r=0.276~0.354,P<0.05或0.01）,TAS-20总评分及各维度评分与DS-14社交抑制维度评分均呈正相关（r=0.224~0.375,P<0.05或0.01）,TAS-20情感描述障碍、情感识别障碍维度评分及总评分与DS-14负性情绪维度评分均呈正相关（r=0.257~0.341,P<0.05或0.01）。结论 抑郁症患者述情障碍与D型人格密切相关。     

新冠肺炎疫情常态化防控下社区居民心理健康状况及相关因素

目的 调查在新冠肺炎疫情常态化防控下社区居民的心理健康状况并分析其相关因素。方法 本研究为横断面调查,采用滚雪球抽样法,于2020年8月28日-9月7日通过问卷星网络平台向居民发放调查问卷。采用患者健康问卷抑郁量表（PHQ-9）、广泛性焦虑量表（GAD-7）、失眠严重程度指数量表（ISI）及中文版知觉压力量表（CPSS）评估居民的心理健康状况。结果 476名居民抑郁、焦虑、失眠及高水平压力症状检出率分别为32.35%、21.22%、24.58%及48.74%。男性高水平压力症状检出率高于女性（χ²=5.269）,未婚、离异或丧偶居民的抑郁及焦虑症状检出率均高于已婚居民（χ²=5.251、8.851）,有心理服务需求的居民抑郁、焦虑、失眠及高水平压力症状检出率均高于无此需求的居民（χ²=46.316、66.934、20.153、21.576）,差异均有统计学意义（P<0.05或0.01）。相关分析显示,社区居民年龄与CPSS评分呈负相关（r=-0.171,P<0.01）,睡眠时间与PHQ-9、GAD-7及ISI评分均呈负相关（r=-0.210、-0.247、-0.297,P均<0.01）,关注疫情信息时长与ISI评分呈负相关（r=-0.097,P<0.05）。结论 在疫情常态化防控下,居民的抑郁、焦虑、失眠及高水平压力症状仍较常见。男性和年轻居民更有可能出现高水平压力症状,睡眠时间短和有心理服务需求的居民更有可能出现抑郁、焦虑及失眠症状,关注疫情信息时长越短越有可能出现失眠症状。     

血小板相关参数对胶质瘤患者预后的影响

目的 探讨术前血小板相关参数对胶质瘤患者肿瘤复发的预测作用。方法 分析联勤保障部队第九〇九医院2015—2017年收治的93例胶质瘤患者临床病理资料,根据随访期间肿瘤是否复发分为无复发组（n=52）和复发组（n=41）,分析血小板相关参数与胶质瘤分级的相关性,采用ROC曲线分析血小板计数（PLT）、血小板体积分布宽度（PDW）、血小板压积(PCT)、平均血小板体积（MPV）、平均血小板体积/血小板计数（MPV/PLT）对肿瘤复发的预测作用,多因素Cox分析肿瘤复发的影响因素,采用Kaplan-Meier曲线分析这些因素对肿瘤复发的影响。结果 胶质瘤Ⅲ、Ⅳ级患者PLT、PCT、高于胶质瘤Ⅰ、Ⅱ级患者（t=-2.388、-2.335,均P<0.05）;胶质瘤Ⅲ、Ⅳ级患者中MPV、MPV/PLT低于胶质瘤Ⅰ、Ⅱ级患者（均P<0.05）;无复发组患者PLT和PCT低于复发组（均P<0.05）;无复发组患者MPV和MPV/PLT高于复发组（均P<0.05）;PLT的ROC曲线下面积（UAC）为0.630（95%CI=0.517~0.743,P=0.032）,阈值为216×10⁹/L;MPV的UAC为0.633（95%CI=0.518~0.747,P=0.029）,阈值为8.65 fL;MPV/PLT的UAC为0.731（95%CI=0.626~0.835,P<0.001）,阈值为0.040;多因素分析结果发现,肿瘤分级（Ⅲ、Ⅳ）、MPV≤8.65 fL、MPV/PLT≤0.040是术后肿瘤复发的危险因素（95%CI分别为1.778~3.530、1.730~4.450、1.811~6.067,均P<0.05）;肿瘤分级（Ⅲ、Ⅳ）预测术后肿瘤复发曲线下面积为0.679（95%CI=0.569~0.789,P=0.003）。Kaplan-Meier曲线分析显示,MPV≤8.65 fL患者术后3年复发率高于MPV>8.65 fL患者（Long Rank=10.990,P=0.001）;MPV/PLT≤0.040患者术后3年复发率高于MPV/PLT>0.040患者（Long Rank=6.289,P=0.012）。结论 胶质瘤患者术前MPV和MPV/PLT与术后肿瘤复发有关,可以用于肿瘤预后预测,具有一定临床意义。 [国际神经病学神经外科学杂志, 2023, 50(4): 29-33]     

Epilepsy and anomalies of neuronal migration: MRI and clinical aspects

Neuronal migration disorders are the result of disturbed brain development. In such disorders, neurons are abnormally located. In diagnosing these conditions, magnetic resonance imaging is superior to any other imaging technique. This enables us to improve our knowledge of the clinical correlates of neuronal migration. With reference to migrational disorder, a retrospective study of all 303 patients with epileptic seizures referred for magnetic resonance imaging during a 3-year period was performed, 13 patients (aged 12-41, mean age 27) were identified. They represent 4.3% of the entire study group. Of the patients with known epilepsy, 6.7% and of the mentally retarded, 13.7% had migrational disorders. Four patients had schizencephaly as the dominant finding, one was classified as hemimegalencephaly, 2 had isolated heterotopias, and 6 had localized pachy- and/or poly-microgyria. The clinical pictures are complex. Ectopias of grey matter are recognised foci of epilepsy, but from an epileptological and a clinical viewpoint little attention has been given to these disorders. The present study shows that malmigration is not rare in epilepsy patients, especially not in the mentally retarded.     

Hepatic Considerations in the Use of Antiepileptic Drugs

Summary: Virtually all of the major antiepileptic drugs (AEDs) can cause hepatotoxicity, although fatal hepatic reactions are rare. The mechanisms, incidences, and risk profiles for such reactions differ from drug to drug. With carbamazepine and phenytoin, hepatotoxicity may be due to drug hypersensitivity. Although the profiles of patients at risk have not been well-defined for these two antiepileptic drugs, it would appear from reports in the literature that older adolescents and adults are at higher risk than children of developing serious or fatal hepatotoxicity. Once hepatotoxicity develops, mortality rates are 10–38% with phenytoin and 25% for carbamazepine. The risk profile for valproate fatal hepatotoxicity has been more clearly defined. Those at primary risk of fatal hepatic dysfunction are children under the age of 2 years who are receiving multiple anticonvulsants and also have significant medical problems in addition to severe epilepsy. The risk is considerably lower for patients over the age of 2 years on valproate monotherapy. In contrast to the risk profile with other AEDs, adults receiving valproate as monotherapy have the lowest risk of hepatotoxicity. Fatal hepatic dysfunction coincident with valproate may be the result of aberrant drug metabolism. Concomitant use of AEDs that induce microsomal P450 enzymes (e.g., phenytoin and phenobarbital) may enhance the production of a toxic metabolite, and hence the greater risk of hepatotoxicity with polypharmacy.     

Vascular Malformations and Epilepsy: Clinical Considerations and Basic Mechanisms

Summary: Vascular malformations (VMs) are associated with epilepsy. The natural history of the various VMs, clinical presentation, and tendency to provoke epilepsy determine treatment strategies. Investigations have probed the mechanisms of epileptogenesis associated with these lesions. Electrophysiologic changes are associated with epileptogenic cortex adjacent to VMs. Putative pathophysiologic mechanisms of epileptogenesis include neuronal cell loss, glial proliferation and abnormal glial physiology, altered neurotransmitter levels, free radical formation, and aberrant second messenger physiology.     

Classification of methods in transcranial Electrical Stimulation (tES) and evolving strategy from historical approaches to contemporary innovations

Transcranial Electrical Stimulation (tES) encompasses all methods of non-invasive current application to the brain used in research and clinical practice. We present the first comprehensive and technical review, explaining the evolution of tES in both terminology and dosage over the past 100 years of research to present day. Current transcranial Pulsed Current Stimulation (tPCS) approaches such as Cranial Electrotherapy Stimulation (CES) descended from Electrosleep (ES) through Cranial Electro-stimulation Therapy (CET), Transcerebral Electrotherapy (TCET), and NeuroElectric Therapy (NET) while others like Transcutaneous Cranial Electrical Stimulation (TCES) descended from Electroanesthesia (EA) through Limoge, and Interferential Stimulation. Prior to a contemporary resurgence in interest, variations of transcranial Direct Current Stimulation were explored intermittently, including Polarizing current, Galvanic Vestibular Stimulation (GVS), and Transcranial Micropolarization. The development of these approaches alongside Electroconvulsive Therapy (ECT) and pharmacological developments are considered. Both the roots and unique features of contemporary approaches such as transcranial Alternating Current Stimulation (tACS) and transcranial Random Noise Stimulation (tRNS) are discussed. Trends and incremental developments in electrode montage and waveform spanning decades are presented leading to the present day. Commercial devices, seminal conferences, and regulatory decisions are noted. We conclude with six rules on how increasing medical and technological sophistication may now be leveraged for broader success and adoption of tES.     

Carbamazepine Efficacy and Utilization in Children

Summary: Carbamazepine is effective for preventing partial and generalized tonic-clonic seizures in children. Although absence epilepsies are more common in children than adults, an estimated 80% of children with epilepsy have seizure types or epilepsies that are potentially responsive to carbamazepine. The differential diagnosis of ictal staring is an especially important issue in children because absence and atypical absence seizures are more prevalent in children than adults. Age-related pharmacokinetic differences and drug interactions are major considerations in children. On average, children have higher clearance rates of carbamazepine, shorter half-lives, and higher ratios of carbamazepine-10, 11-epoxide to carbamazepine than adults. In addition, children with severe epilepsy are more likely to require multiple-drug therapy, which can lead to complex drug interactions. When carbamazepine is administered along with valproate, drug protein binding interactions can cause intermittent side effects.     

Neonatal Seizures: Problems in Diagnosis and Classification

Summary: The clinical identification of neonatal seizures is critical for the recognition of brain dysfunction; however, diagnosis is often difficult because of the poorly organized and varied nature of these behaviors. Current classification systems are limited in their ability to communicate motor, autonomic, and electroencephalo-graphic features of seizures precisely and to provide a basis for uniform effective diagnosis, therapy, and determination of prognosis. Recent investigations of neonates, utilizing bedside electroencephalographic/polygraphic/ video monitoring techniques, have provided the basis for improved diagnosis and classification of seizures in the newborn. These studies have demonstrated that not all clinical phenomena currently considered to be seizures require electrocortical epileptiform activity for their initiation or elaboration. In addition, the specific clinical character of the phenomena considered to be seizures, the clinical state of the infant, and the character of the EEG indicate the probable pathophysiological mechanisms involved and suggest probable etiologies, prognosis, and therapy. Similarities between animal models that demonstrate reflex physiology and neonates with motor automatisms and tonic posturing suggest that these clinical behaviors may not be epileptic in origin but, rather, primitive movements of progression and posture mediated by brainstem mechanisms. Although not all clinical behaviors currently considered to be neonatal seizures may have similar pathophysiological mechanisms, they are clinically significant because they all indicate brain dysfunction.     

Valproate Monotherapy in the Management of Generalized and Partial Seizures

Summary: For decades, therapeutic tradition has promoted the concept of polypharmacy in the management of epilepsy. In recent years, however, studies have shown that, for most patients, monotherapy can provide comparable or better seizure control than administration of multiple anticonvulsants, while diminishing the potential for adverse reactions, drug interactions, and poor compliance. Valproate is an important monotherapeutic agent that is highly effective in the control of idiopathic primary and secondarily generalized epilepsies, and partial seizures that do not generalize. Comparative studies have found that valproate is at least as effective as phenytoin and carbamazepine in the treatment of generalized and partial seizures. Given the similar efficacy, other factors such as pharmacokinetics and side effects may therefore determine anticonvulsant selection for monotherapy.     

Un nouveau cadre conceptuel de travail pour la psychiatrie

In an attempt to place psychiatric thinking and the training of future psychiatrists more centrally into the context of modern biology, the author outlines the beginnings of a new intellectual framework for psychiatry that derives from current biological thinking about the relationship of mind to brain. The purpose of this framework is twofold. First, it is designed to emphasize that the professional requirements for future psychiatrists will demand a greater knowledge of the structure and functioning of the brain than is currently available in most training programs. Second, it is designed to illustrate that the unique domain which psychiatry occupies within academic medicine, the analysis of the interaction between social and biological determinants of behavior, can best be studied by also having a full understanding of the biological components of behavior.     

Special Pharmacokinetic Considerations in Children

Summary: Pediatric patients have greater degrees of pharmacokinetic variability and unpredictability than adults. This variability results from the effects of pharmacogenetics, age and growth, prior and current comedication, and disease. Newborns with seizures have the least predictable dosage requirements, and their needs change as drug-eliminating mechanisms mature in the neonatal period. Infants have the highest relative capacities to eliminate antiepileptics of any age group and require the largest relative doses. In addition to age-related trends, children demonstrate the same drug-specific, pharmacokinetic phenomena that adults do, including nonlinear phenytoin elimination, nonlinear valproate binding, and autoinduction of carbamazepine. Intercurrent illness and drug interactions further modify the age-related pharmacokinetic patterns in children and make dosage requirements even more unpredictable. Recent studies have shown that febrile illness can affect drug elimination, sometimes decreasing drug levels by 50% or more. Intermittent treatment with benzodiazepines administered either orally or rectally can be an important adjunct and help minimize this type of problem for children with marginally controlled epilepsy. Intermittent benzodiazepines are also helpful for children who have febrile seizures and who need only occasional antiepileptic protection.