Interdisciplinary research: noradrenergic regulation of adaptive immunity

To understand the complexity of mechanisms involved in the regulation of adaptive immunity by the sympathetic neurotransmitter norepinephrine and adrenergic receptor stimulation, there must be a rich history of basic science and clinical findings upon which to form hypotheses for testing, as well as a rich supply of individuals trained in two or more disciplines. This review is intended to offer a tour of the past, present, and future discoveries that have been made in the area of adrenergic regulation of adaptive immunity, as well as share a vision of how our field of study will progress years from now, given that every individual who contributes to the interdisciplinary nature of our research is valued. And finally, this review will discuss how the lessons from the past can help us to attain a vision of interdisciplinary research for the future.     

Naturalism’s Perils,Naturalism’s Promises: A Comment on Appiah’s <Emphasis Type="Italic">Experiments in Ethics</Emphasis>

In his Experiments in Ethics, Appiah focuses mostly on the dimension of naturalism as a naturalism of deprivation - naturalism’s apparent robbing us of aspects of the world that we had held dear. The aim of this paper is to remind him of that naturalism has a dimension of plenitude as well - its capacity to enrich our conception of the world as well. With regard to character, we argue that scientific psychology can help provide a conception of character as dynamic, in a way that may preserve many key aspects of eudaimonistic ethics from the situationists’ challenge. With regard to intuition, we address Appiah’s worry that naturalistic explanations of the sources of our intuitions may leave us feeling that those intuitions have been thereby debunked. We suggest that it may be that feeling of debunking that should itself be debunked.     

Lessons from psychiatry and psychiatric education for medical learners and teachers

Abstract

Medical learners, teachers, and institutions face significant challenges in health care delivery and in training the next generation of clinicians. We propose that psychiatry offers lessons which may help improve how we take care of patients and how we teach others to care for patients. Our objective is to discuss what learners and teachers can learn from psychiatry, organized around (1) how we make decisions, (2) how we learn, and (3) how we reflect on our practice. Information from clinical care, education, neuroscience and other aspects of life (e.g. business, creativity, and research) help us on these processes. We make ‘good’ decisions in concert with patients and learners, by listening to their experiences, asking questions and exploring subjective and objective information. Our learning has a neurobiological basis, and is effectively furthered by personalization, reinforcement, acquisition of critical thinking skills, and assessment of our limitations and errors. Our ability to reflect is determined by attitude, skill, tolerating ambiguity or dissonance, and planning for the unexpected. These processes – in addition to knowledge and other skills – will help physicians be successful in practice, learning and teaching, research and leadership.     

COVID-19: Neurology residents’ perspective

Throughout this pandemic, neurology resident education and service has, and will continue to be, affected during this unprecedented time. Balancing the safety of our residents as well as the anticipated inpatient service demands, we have, and continue to, make changes to meet the needs of our community. Education certainly has been affected but we have made great effort to maintain normalcy. We are leveraging web-based technologies to continue formal didactics. The American Academy of Neurology has provided program directors with various tools to share to provide high-yield academic education. AAN Synapse, distance learning modules, and podcasts are a few examples. Each residency training program will likely face different challenges depending on location and community structure. We have an obligation to help all of our colleagues in the hospital in providing quality and compassionate care during this time of need. Our training and education will only benefit from this experience teaching us lessons on adaptability, the importance of teamwork, and self-sacrifice.     

The role of endovascular treatment for pediatric aneurysms

Objectives To review all cases of pediatric aneurysms, we treated and evaluated their characteristics. The objective of the study is to compare between surgical and endovascular approaches regarding treatment and outcome.Methods All cases of pediatric intracranial aneurysms diagnosed and managed by our team in the last 12 years were prospectively collected in our vascular malformation data base and reviewed.Conclusion Pediatric aneurysms differ in their features when compared to adult aneurysms. Over the last years, there has been a gradual shift from traditional surgical approaches towards endovascular treatment of pediatric aneurysms. In our experience, patients treated by endovascular means had a better outcome than when treated by surgery. Whenever possible, endovascular treatment for pediatric aneurysms is the recommended approach. This offers both constructive and deconstructive techniques. Improved understanding with respect to the etiology of pediatric aneurysms will be the next step that will likely lead us to even better treatment decisions.     

The Analyst’s Achilles’ Heels: Owning and Offsetting the Clinical Impact of Our Intrinsic Flaws

Abstract

The analyst’s inveterate characterological weaknesses and deficits—say, being detached, distracted, over-aggressive, too literal, etc.—may elude identification, correction, or repair during the training years and beyond. Such “Achilles’ heels” in a clinician will taint at least some of the analytic relationships this clinician forms and compromise the outcome of the therapeutic work with those patients. The defenses the analyst may erect against recognizing their vulnerability amplify its disadvantageous effect. This article explores how we might more effectively register such Achilles’ heels in ourselves. Homing in on specific instances in the literature and my own practice, I trace the impact of our intrinsic deficiencies within the transference/countertransference matrix, and offer a perspective on how to address and mitigate their deleterious effects. My purpose is to help us, as analytic clinicians, relax our inherent anxieties about recognizing our frailties, so we can more creatively and effectively offset any negative influence these may have on our therapeutic functioning.     

Pediatric headaches: what's new?

The evolution of headache from childhood into adulthood is receiving greater attention as questions arise regarding prevalence and long-term remission rates. Presenting symptoms of headache in childhood and adolescence tend to differ from those in adults, making it difficult to obtain high sensitivity ratings using the present standard International Headache Society criteria specifically with regard to migraine. The new treatment options that have been available for adults for several years are now being studied in childhood and adolescent populations. Are they safe and effective, and is there a need to alter dosages in this population? The interest in chronic daily headache in childhood and adolescence is increasing because studies in this population may help us to advance our knowledge with regard to adult chronic daily headache.     

Schizophrenic thought disorder: a model-theoretic perspective

Model theory is a branch of mathematics that treats such abstruse questions as "is there another number system, different from 0,1,2, ... that satisfies all the axioms of arithmetic?" (yes), and "can every mathematical hypothesis be proved true or false?" (no). It would not seem likely that any contribution could be made to our understanding of though disorder in schizophrenia from such a remote quarter. The detailed results of model theory obviously will not apply; but I believe certain ways of thinking common in that field, but not in psychology, may help lead us toward explanations.     

Topiramate in clinical practice: long-term experience in patients with refractory epilepsy referred to a tertiary epilepsy center

For the treatment of patients with chronic refractory epilepsies, information about the long-term efficacy and safety profile of any new antiepileptic drug is crucial. Topiramate has been proven to be effective in patients with refractory chronic partial epilepsies in short-term controlled clinical trials, but the long-term retention, long-term efficacy, and long-term side-effect profile have not been sufficiently investigated. We analyzed all patients who had been treated with topiramate in the Epilepsy Centre Kempenhaeghe from the introduction of the drug in the spring of 1993 up to a final assessment point in mid-2002. In total, 470 patients were identified. The data show that the clinical dose achieved was about 200mg/day, reached after approximately 6 months of treatment. Further dose escalation in the survivors was slow, with a mean dose of about 300 mg/day after 24 months of treatment. Mean titration dose is 25mg/week, but titration strategy is mostly individual and responds to patient complaints. With respect to seizure frequency, 10-15% of the patients were seizure-free at the 6-month evaluation; 4 patients achieved a 2-year remission. Retention rate was 53% after 1 year, 45% after 2 years, 38% after 3 years, and 30% after 4 years. At 4 years, almost 70% of the patients had discontinued topiramate. The main reason was adverse events, which accounted for about 65% of the discontinuations. Behavioral side effects were dominant, with mental slowing (27.6%), dysphasia (16.0%), and mood problems (agitation: 11.9%) being the most frequently reported side effects. In about 10% of the patients side effects led to discontinuation despite the obvious favorable effects on seizure frequency. Comparisons between the patients who discontinued topiramate treatment and those who continued topiramate showed that discontinuation was associated with comedication (vigabatrin and lamotrigine). Our conclusion is that TPM is associated with a high incidence of side effects in clinical practice, affecting long-term retention. Meaningful prognostic factors that may help us in clinical decision making, i.e., to prevent the side effects or to help us identify those at risk, have not been found.     

Hostile interactions between body and self

Our body houses the various selves we are. It continuously informs us about the position of its limbs, both relative to themselves and relative to the trunk and head. It allows us to feel touch, to reach out and touch others, and to differentiate between passively received and self-delivered touch. It provides us with information about temperature, pressure, and gravity. and it mediates basic sensations, feelings, and emotions, from pain, fatigue, and hunger to relaxation, lust, and ticklish joy. Enabling us to look up to the stars, it even shows us how small we are, how limited in reach, and how alone most of the time. Only our body is constantly present; it is the only object that abidingly stays with us throughout our lives, it is perhaps this continuity that binds together the different components of our self - sensory-receptive, motor-agentive, emotional - and makes us feel that we are one self in one body.All this said, we note that there are various neurological conditions in which the unit y between body and self is thoroughly shaken. We may no longer acknowledge ownership of parts of the body, or we may deny agency over bodily actions. We may feel alienated or spatially separated from our body, or project the experience of touch info objects in extracorporeal space. Although not obligatorily eliciting a morbid reaction, such disintegrations between body and self occasionally induce overt hostility. The present note provides a glimpse into some major types of auto-aggression after body-self fragmentation.     

Problematic internet use: proposed classification and diagnostic criteria

Since the mid-1990s, there have been frequent reports of individuals whose use of the computer and internet is problematic. Given the recent expansion and the expected increase in internet availability and usage in the coming years, it is important that healthcare professionals be informed about this behavior and its associated problems. Recently, psychological and psychiatric literature has described individuals that exhibit problematic internet use who often suffer from other psychiatric disorders. In the face of this comorbidity, it is essential to evaluate whether these individuals represent a distinct class of disorder, or a manifestation/coping mechanism related to other underlying diagnosis. In either event, problematic internet use negatively impacts social and emotional functioning. Based on the current limited empirical evidence, problematic internet use may best be classified as an impulse control disorder. It is therefore imperative that problematic internet use be appropriately identified among symptomatic individuals. For these reasons, we propose specific diagnostic criteria that will allow for consistent identification and assist in further study of this behavior.     

Premorbid indicators and risk for schizophrenia: a selective review and update

Prospective studies of young relatives at risk for schizophrenia (high-risk studies, HR) can shed light on premorbid precursors of schizophrenia. Early HR studies pointed to a wide prevalence of schizophrenia spectrum psychopathology among young relatives at increased genetic risk. Recent studies suggest that young HR relatives have neurobehavioral deficits and structural, physiological, and neurochemical brain abnormalities that may date back to childhood or earlier. In this paper, we provide a selected overview of the lessons and limitations of early "first generation" studies and the beginning insights from recent "second generation" studies. We also provide an interim summary of data from the ongoing studies of young relatives at risk for schizophrenia in Pittsburgh. Collectively, such data may help us to predict the eventual emergence of schizophrenia, and schizophrenia spectrum or non-spectrum psychopathology.     

One of the giants of neurological surgery left us more than a decade ago, and neurosurgical literature did not show much interest

One of the giants of neurological surgery left us over a decade ago. Charles George Drake died September 15, 1998 in London, Ontario after an extended bout with lung cancer. Although he will always be identified with taking posterior fossa aneurysm surgery from the realm of the daring to the domain of the routine, his contributions were much broader. Clinical neurosciences have been blessed in the past century by the life and works of Drake. In the neurosurgical world, the achievements of Drake are very well known and have been well recorded. Unfortunately, in the past decade since his passing, only one paper has been published about him and his contributions to neurosurgery. This is a historical paper regarding Charles George Drake that attempts to (1) remember Drake as a pioneer; (2) to evaluate lessons that we have learned from him; and (3) to address the question ‘What made him great?’. As per Drake's teachings, this paper is meant to articulate the unique perspectives Charlie provided with respect to how we learn our craft, maintain the integrity of reporting, and implement suggestions as to how we may progress into the future. In conclusion, it is our hope that this paper will bring to life the unique character of Drake and his unprecedented blend of genius, creativity, technical skill, introspection, and ever-present humility for all international neurosurgeons to appreciate.     

Neurología y Literatura 2

Introduction

Good literary fiction has the potential to move us, extend our sense of life, transform our prospective views and help us in the face of adversity. A neurological disorder is likely to be the most challenging experience a human being may have to confront in a lifetime. As such, literary recreations of illnesses have a doubly powerful effect.

Objectives

Study the synergies between neurology and fictional literature with particular reference to narrative based medicine (NBM).

Development

Doctors establish boundaries between the normal and the abnormal. Taking a clinical history is an act of interpretation in which the doctor integrates the science of objective signs and measurable quantities with the art of subjective clinical judgment. The more discrepancy there is between the patient's experience with the illness and the doctor's interpretation of that disease, the less likely the doctor-patient interaction is to succeed. NBM contributes to a better discernment of the meanings, thus considering disease as a biographical event rather than just a natural fact. Drawing from their own experience with disease, writers of fiction provide universal insights through their narratives, whilst neuroscientists, like Cajal, have occasionally devoted their scientific knowledge to literary narratives. Furthermore, neurologists from Alzheimer to Oliver Sacks remind us of the essential value of NBM in the clinic.

Conclusions

Integrating NBM (the narrative of patients) and the classic holistic approach to patients with our current paradigm of evidence based medicine represents a challenge as relevant to neurologists as keeping up with technological and scientific advances.     

Neuropeptides in Alzheimer's disease. Clinical implications

Since the isolation and sequencing of the enkephalins in the mid-1970s, there has been an explosion of knowledge concerning putative peptide neurotransmitters in the brain. This article focuses on selected developments in neuropeptide research that may have bearing on our understanding of and clinical approach to the dementing degenerative disorder Alzheimer's disease (AD), a cardinal feature of which is impairment of memory.     

Intraventricular insulin increases dopamine transporter mRNA in rat VTA/substantia nigra

The hormone insulin can down-regulate the function and synthesis of the re-uptake transporter for norepinephrine (NET) in vivo and in vitro. In the present study we tested whether this action of insulin is generalized to another member of the catecholamine transporter family. We determined the level of dopamine transporter (DAT) mRNA expression in the ventral tegmental area (VTA)/substantia nigra compacta (SNc) of rats which were chronically treated with vehicle or insulin via the third cerebral ventricle (i.c.v.). DAT mRNA was significantly elevated in the VTA/SNc of rats treated with insulin, as compared with levels in vehicle-treated rats. This is in contrast to our previous observation that i.c.v. insulin decreases NET mRNA in the rat locus coeruleus, and suggests that insulin may have differential and specific modulatory effects on CNS catecholaminergic pathways.     

The reasons for using restraint and seclusion in psychiatric inpatient care: A nationwide 15-year study

We present bibliometric methods that can be utilized in evaluation processes of scientific work. In this paper, we present some practical clues using Finnish schizophrenia research as an example and comparing the research output of different institutions. Bibliometric data and indicators including publication counts, impact factors and received citations were used as tools for evaluating research performance in Finnish schizophrenia research. The articles and citations were searched from the Web of Science database. We used schizophrenia as a keyword and defined address Finland, and limited years to 1996–2005. When we analysed Finnish schizophrenia research, altogether 265 articles met our criteria. There were differences in impact factors and received citations between institutions. The number of annually published Finnish schizophrenia articles has tripled since the mid-1990s. International co-operation was common (43%). Bibliometric methods revealed differences between institutions, indicating that the methods can be applied in research evaluation. The coverage of databases as well as the precision of their search engines can be seen as limitations. Bibliometric methods offer a practical and impartial way to estimate publication profiles of researchers and research groups. According to our experience, these methods can be used as an evaluation instrument in research together with other methods, such as expert opinions and panels.     

How to use bibliometric methods in evaluation of scientific research? An example from Finnish schizophrenia research

We present bibliometric methods that can be utilized in evaluation processes of scientific work. In this paper, we present some practical clues using Finnish schizophrenia research as an example and comparing the research output of different institutions. Bibliometric data and indicators including publication counts, impact factors and received citations were used as tools for evaluating research performance in Finnish schizophrenia research. The articles and citations were searched from the Web of Science database. We used schizophrenia as a keyword and defined address Finland, and limited years to 1996-2005. When we analysed Finnish schizophrenia research, altogether 265 articles met our criteria. There were differences in impact factors and received citations between institutions. The number of annually published Finnish schizophrenia articles has tripled since the mid-1990s. International co-operation was common (43%). Bibliometric methods revealed differences between institutions, indicating that the methods can be applied in research evaluation. The coverage of databases as well as the precision of their search engines can be seen as limitations. Bibliometric methods offer a practical and impartial way to estimate publication profiles of researchers and research groups. According to our experience, these methods can be used as an evaluation instrument in research together with other methods, such as expert opinions and panels.     

Problems of a temporary adolescent psychiatrist.

I have tried to describe just less than one year of learning experience on my part in one type of adolescent unit. Only 16 inpatients were treated at a time while I was there: there were only 25 discharges and 19 admissions in my time. We knew we were making little inroad into our whole regional problem of adolescent disturbance; but we believe that as a team, able to work closely with each other and with our patients and their relatives, in a therapeutic community of undogmatic ideology, we were able to give a little to almost all and, to those who did best, a great deal. Very few ex-inpatients lost all touch with us. Nearly all came back from scattered homes for our Christmas discotheque. Even our very modest aim, to reset and then foster the natural development of the personalities of our patients, rather than break them down in deep analysis and radically reconstruct them, required an intensity of psychotherapeutic effort which engaged all we had to offer, and often drained us at the end of the day. Yet those who joined us transiently, particularly student nurses and medical students, seemed to find the experience significant--occasionally deeply so--and came back to visit us. Our social worker has now departed to have a baby. Our three senior nurses have left, two to university as mature students, one to prepare for a no. 7 post. Possibly the intensity of the demand upon them would have made them leave, anyway. For myself, it was a year of development of my psychotherapeutic sensitivity and of close working with a valued team of colleagues in a setting new to me, which I shall never forget.