Unilateral pallidotomy in advanced Parkinson's disease: a retrospective study of 26 patients.

OBJECTIVE: To evaluate the effects of unilateral pallidotomy in patients with Parkinson's disease (PD). PATIENTS AND METHODS: Twenty-six patients with PD and disabling dyskinesias, painful and/or disabling dystonia, and/or pain as part of PD despite optimal pharmacotherapy underwent unilateral pallidotomy. For assessment, the Unified Parkinson's Disease Rating Scale (UPDRS; part II and III), Hoehn and Yahr staging, the Schwab and England scale, a Dyskinesia Rating Scale, and timed tests were used. Assessment was performed in defined "off' and "on," and on average 2 months before and 7.5 months after the unilateral pallidotomy. Adverse effects were classified as transient or permanent and as major or minor. RESULTS: In the "off' phase, the median UPDRS II score improved from 26.5 to 20.5 (23%) and the median UPDRS III score improved from 47.5 to 33.0 (31%). In the "on" phase, dyskinesias contralateral to the side of the procedure improved with 88% ipsilateral dyskinesias improved only temporarily, and the total UPDRS II and III scores remained unchanged. Thirteen patients had transient adverse effects, three patients had permanent, and two patients had a combination of transient and permanent adverse effects. The transient adverse effects in two patients were classified as major. CONCLUSION: Stereotactic unilateral pallidotomy can improve symptoms and disability in the "off' phase. In the "on" phase, dyskinesias disappeared at the side contralateral to the procedure. Permanent minor complications of pallidotomy occurred in 19% of the patients.     

Cognitive effects of unilateral posteroventral pallidotomy: a 4-year follow-up study.

We assessed the long-term neuropsychological effects of unilateral posteroventral pallidotomy in Parkinson's disease. Eleven Parkinson's disease patients, from an original cohort of 15 consecutive patients who underwent pallidotomy, were evaluated. A neuropsychological battery was administered to each patient before (3 days) and after (3 months and 4 years) surgery during the effects of levodopa. The following tests were administered: Rey's Auditory-Verbal Learning Test, Visual Associative Learning test from the Wechsler Memory Scale-Revised, Luria's motor alternation, Benton's Judgment of Line Orientation, Trail Making, phonetic verbal fluency, Stroop test, Petrides' working memory tasks, Beck's depression questionnaire and the Maudsley obsessional-compulsive inventory. In the 3-month postoperative assessment, there was a significant worsening in phonetic verbal fluency and an improvement in Benton's Judgment of Line Orientation test. In the 4-year follow-up assessment, phonetic verbal fluency and Benton's Judgment of Line Orientation test returned to baseline scores. Although there was no significant difference between pre- and postsurgical scores for long-term visual associative memory, there was a significant deterioration between 3-month and 4-year follow-up performances. Our results suggest that unilateral posteroventral pallidotomy may produce transient changes in prefrontal and visuospatial functions, but there is no evidence of permanent neuropsychological effects.     

Long-term clinical effect of group cognitive behavioral therapy for insomnia: a case series study

ObjectiveCognitive-behavioral therapy for insomnia (CBT-I) is recognized as the first-choice intervention for insomnia. One of the best-known advantages of CBT-I in comparison with pharmacotherapy is its long-term effect. However, only few studies have assessed its benefits with follow-up periods of longer than three years. In this clinical case series study we aimed to describe the long-term effects of group CBT-I after a mean 7.8 ± 1.6 years of follow-up (range 4–10 years).MethodsA total of 292 insomnia disorder (ID) patients were consecutively enrolled at the Sleep Disorders Center of San Raffaele Hospital, Milan; 123 patients (82 (66.7%) females and 41 (33.3%) males, mean age 40.59 ± 11.89 years) completed the follow-up evaluation within a range of 4–10 years.ResultsIn the 258 patients who completed the treatment, insomnia severity index (ISI) total score improved significantly as well as all variables of the sleep diaries. Using ISI as the primary outcome, we demonstrated that the effect of CBT-I is maintained up to 10 years after the end of treatment. Furthermore, we found that patients that used only CBT-I techniques to deal with relapses were the ones with better outcomes, in particular compared to the patients that re-used medications.ConclusionTo the best of our knowledge this is the longest follow-up evaluation in the literature, both for group and individual CBT-I. These findings have an important clinical implication both suggesting and confirming that CBT-I can be considered the treatment of choice for insomnia.     

The management of epilepsy in children: cognitive and behavioral side effects

Despite the fact that epilepsy disproportionately affects children, a lack of information exists on cognitive and behavioral side effects of anticonvulsant drug (AED) use in children. This review discusses suggested approaches to optimizing the neurological and psychological well-being of children with epilepsy. Recommended is a multifaceted approach that focuses on evaluating cognitive and behavioral issues in children with epilepsy, staying vigilant to the potential adverse effects of several older AEDs, and employing a wide range of multidisciplinary treatments.     

The stability of cognitive and behavioral parameters in autism: a twelve-year prospective study

Sixty-two autistic patients enrolled in a prospective study an average of 12 years ago. Current retesting results are now available on 53 of the original 62 patients (85.5%). Results indicate that 36 (67.9%) achieved scores within their original IQ group. Twelve (22.6%) moved up IQ groups and five (9.4%) moved down. Of particular clinical importance is the observation that Vineland Adaptive Behavior Scores were consistently lower than cognitive scores, and maladaptive behaviors occurred with equal frequency in the high, medium, and low IQ groups. The implications of this new data for understanding the natural history of autism, educational and vocational planning, and future research are discussed.     

Unilateral and bilateral pallidotomy for idiopathic Parkinson's disease: a case series of 115 patients.

Lesioning of the internal pallidum is known to improve the symptoms of idiopathic Parkinson's disease (PD) and alleviate dyskinesia and motor fluctuations related to levodopa therapy. The benefit obtained contralateral to a single lesion is insufficient in some cases when symptoms are bilaterally disabling. However, reports of unacceptably high rates of adverse effects after bilateral pallidotomy have limited its use in such cases. We report on the outcome of unilateral (UPVP) and bilateral (BPVP) posteroventral pallidotomy in a consecutive case series of 115 patients with PD in the United Kingdom and Australia. After 3 months, UPVP resulted in a 27% reduction in the off medication Part III (motor) Unified Parkinson's Disease Rating Scale score and abolition of dyskinesia in 40% of cases. For BPVP, these figures were increased to 31% and 63%, respectively. Follow-up of a smaller group to 12 months found the motor scores to be worsening but benefit to dyskinesia and activities of daily living was maintained. Speech was adversely affected after BPVP, although the change was small in most cases. Unilateral and bilateral pallidotomy can be performed safely without microelectrode localisation. Bilateral pallidotomy appears to be more effective, particularly in reducing dyskinesia; in our experience, the side effects have not been as high as reported by other groups.     

Clinical effectiveness of a cognitive behavioral group treatment program for anxiety disorders: A benchmarking study

Previous research has established efficacy of cognitive behavioral therapy (CBT) for anxiety disorders, yet it has not been widely assessed in routine community clinic practices. Efficacy research sacrifices external validity to achieve maximum internal validity. Recently, effectiveness research has been advocated as more ecologically valid for assessing routine clinical work in community clinics. Furthermore, there is a lack of effectiveness research in group CBT. This study aims to extend existing research on the effectiveness of CBT from individual therapy into group therapy delivery. It aimed also to examine outcome using not only symptom measures, but also measures of related symptoms, cognitions, and life quality and satisfaction. Results from a cohort of patients with various anxiety disorders demonstrated that treatment was effective in reducing anxiety symptoms to an extent comparable with other effectiveness studies. Despite this, only 43% of individuals showed reliable change, and 17% were ‘recovered’ from their anxiety symptoms, and the post-treatment measures were still significantly different from the level of anxiety symptoms observed in the general population.     

The efficacy of integrated cognitive behavioral therapy (CBT) and acupressure versus CBT for insomnia: a three-arm pilot randomized controlled trial

ObjectivesThis pilot study aimed to examine the efficacy of integrated cognitive behavioral therapy (CBT) and acupressure in treating insomnia and its daytime impairments in a Chinese adult population.Methods40 eligible participants with insomnia were randomly assigned to either the integrated CBT and acupressure (CBTAcup) group (n = 14), the CBT group (n = 13), or the waitlist control (WL) group (n = 13). Participants in the CBTAcup group attended a 2-hour integrated CBT and self-administered acupressure group treatment once per week for six consecutive weeks, while participants in the CBT group attended six weekly 2-hour CBT for insomnia. Sleep, mood, daytime impairments, quality of life, and treatment credibility and adherence were assessed at baseline, immediate post-treatment (Week 7), and 4-week post-treatment (Week 11).ResultsLinear mixed-effects models showed that both the CBTAcup and CBT groups had significantly lower insomnia severity (d = −1.74 and d = −2.61), dysfunctional beliefs related to sleep (d = −2.17 and −2.76), and mental fatigue (d = −1.43 and −1.60) compared with the WL group at Week 7. The CBTAcup group provided additional benefits in reducing total fatigue (d = −1.43) and physical fatigue (d = −1.45). Treatment credibility was found to be improved in the CBTAcup group from baseline to Week 7.ConclusionsIntegrated CBT and acupressure demonstrated comparable efficacy to pure CBT in treating insomnia symptoms, with additional advantages to improve fatigue symptoms and acceptability in the Chinese population. Further methodologically rigorous studies on a larger scale and longer follow-up are warranted to confirm these findings.     

Pergolide monotherapy in the treatment of early PD: a randomized, controlled study. Pergolide Monotherapy Study Group.

OBJECTIVE: To determine whether pergolide monotherapy provides symptomatic relief in early PD. BACKGROUND: Early treatment with dopamine agonists may reduce the risk of motor fluctuations, which are most likely linked to levodopa therapy. Pergolide, a D1-D2 dopamine agonist, has been studied as "add on" therapy in PD, but no controlled clinical trial studying the efficacy of pergolide monotherapy is available. METHODS: The efficacy and tolerability of pergolide were evaluated in a multicenter, double-blind, randomized, parallel-group, 3-month trial versus placebo. Patients with a diagnosis of idiopathic PD, a modified Hoehn & Yahr score of 1 to 3, and a score greater than 14 points on the Unified Parkinson's Disease Rating Scale (UPDRS) part III at baseline were enrolled in the study (pergolide, n = 53; placebo, n = 52). RESULTS: Patient characteristics at study entry were comparable in the two study groups. The pergolide group showed a significantly greater percent of responders (defined as a -30% decrease in UPDRS part III score at end point) compared with placebo (57% versus 17%; p < 0.001). Pergolide-treated patients experienced a significantly greater improvement than placebo-treated patients (p < 0.001) in UPDRS (overall, part II, and part III) score, Schwab & England score, and Clinical Global Impression improvement score. By the study end the mean dose of pergolide was 2.06 mg/day. Six patients in the pergolide group versus two patients in the placebo group discontinued the study because of treatment emergent side effects. CONCLUSION: This study suggests that pergolide monotherapy may be an efficacious and well-tolerated first-line treatment in patients with early-stage PD.     

Bilateral pallidotomy in Parkinson's disease: a retrospective study.

We evaluated the effects of bilateral pallidotomy in patients with advanced Parkinson's disease. Thirteen patients with Parkinson's disease had a staged bilateral pallidotomy if they had severe response fluctuations, dyskinesias, painful dystonia, or bradykinesia despite optimum pharmacological treatment. Assessment scales were the Unified Parkinson's Disease Rating scale (UPDRS), the Schwab and England scale, and a questionnaire on the effects of disability in activities of daily living and adverse effects. Postoperative magnetic resonance imaging was evaluated for lesion location and extension. The median off-phase UPDRS motor score was reduced from 43.5 to 29 after the first pallidotomy, and it was further reduced to 23.5 after the second pallidotomy (n = 8). The UPDRS activities of daily living off-phase score improved from 28.5 to 20.5 after the first pallidotomy and to 19 after the second pallidotomy (n = 6). The Schwab and England scale off-phase score showed an improvement after both procedures, first from 40 to 60, and thereafter to 90 (n = 8). On-phase dyskinesias were reduced substantially. Eight patients had adverse effects, of whom five had problems with speech. One patient became hemiplegic due to a delayed infarction. Ten patients experienced further benefit from the second procedure. Bilateral pallidotomy reduces dyskinesias. A second contralateral pallidotomy may reduce parkinsonism, although to a lesser degree compared with the first pallidotomy and with an increased risk for adverse effects.     

A controlled study into the (cognitive) effects of exposure treatment on trauma therapists

Several researchers have reported on therapists’ symptoms as a result of trauma treatment, such as disruptions in cognitive schemata and symptoms resembling PTSD-symptoms. Thus far, however, no studies compared the symptoms of trauma therapists and non-trauma therapists. In the present study, both trauma therapists (n=20) and non-trauma therapists (n=19) were included. During semi-structured interviews, both therapist groups reported negative and positive effects of their work with patients on their personal and professional functioning. Trauma therapists reported more often changes of cognitions due to trauma work. Results from questionnaires, however, showed that compared with norm-standards and compared with non-trauma therapists, trauma therapists did not show enhanced psychopathology nor distorted cognitive schemata. It is concluded that although exposure treatments with trauma patients are associated with therapists’ distress, therapists seem able to cope with it in a healthy way.     

The effects of 7-week cognitive training in patients with vascular cognitive impairment,no dementia (the Cog-VACCINE study): A randomized controlled trial

IntroductionEvidence for the efficacy of cognitive training in patients with subcortical vascular cognitive impairment no dementia is still lacking.MethodsA randomized, active controlled design using multidomain, adaptive, computerized cognitive training for 30 minutes, 5 days/week for 7 weeks. Assessments included global cognitive function and executive function (primary outcomes) and brain functional connectivity and structural changes (secondary outcomes).ResultsSixty patients were randomized across three medical centers in Beijing. At the end of the intervention, the cognitive training group showed significant improvement in Montreal Cognitive Assessment relative to the active control group (P = .013) and significantly increased functional connectivity between the left dorsolateral prefrontal cortex and medial prefrontal cortex, which was significantly correlated with Montreal Cognitive Assessment change (P = .017).DiscussionComputerized cognitive training significantly improved global cognitive function, which was supported by the improved brain plasticity. Incorporation of biomarkers should be implemented in cognitive training trials.     

The effect of psychotherapy in patients with PD: A controlled study

The purpose of this study was to evaluate whether group psychotherapy was effective in improving of quality of life and would decrease the symptoms of anxiety and depression in Parkinson's disease patients. Sixteen subjects, with idiopathic Parkinson's disease recruited from the school clinical Hospital/UNICAMP. Were randomly divided in to two groups, experimental and control. Parkinson's Disease and Quality of Life – PDQL; Beck Depression Inventory – BDI; State-Trait-Anxiety Inventory – STAI were used to evaluate the patients. The statistical analysis showed significant effect of the interaction group vs. time in depression (0.0009), anxiety (<0.0001) and QuoL (0.0018) and positive changes in depression (0.0029), anxiety (0.0009) and QuoL (0.0047) for the treated group.     

Neurophysiological and behavioral effects of multisession prefrontal tDCS and concurrent cognitive remediation training in patients with autism spectrum disorder (ASD): A double-blind,randomized controlled fNIRS study

BackgroundThe clinical effects and neurophysiological mechanisms of prefrontal tDCS and concurrent cognitive remediation training in individuals with autism spectrum disorder (ASD) remain unclear.ObjectiveThis two-armed, double-blind, randomized, sham-controlled trial aimed to investigate the beneficial effects of tDCS combined with concurrent cognitive remediation training on adolescents and young adults with ASD.MethodsParticipants were randomly assigned to either active or sham tDCS groups and received 1.5 mA prefrontal tDCS with left dorsolateral prefrontal cortex (dlPFC) cathode placement and right supraorbital region anode placement for 20 minutes over two consecutive weeks. tDCS was delivered concurrently with a computerized cognitive remediation training program. Social functioning and its underlying cognitive processes, as well as prefrontal resting-state functional connectivity (rsFC), were measured.ResultsThe results from 41 participants indicated that multisession prefrontal tDCS, compared to sham tDCS, significantly enhanced the social functioning of ASD individuals [F(1,39) = 4.75, p = .035, η_p² = 0.11]. This improvement was associated with enhanced emotion recognition [F(1,39) = 8.34, p = .006, η_p² = 0.18] and cognitive flexibility [F(1,39) = 4.91, p = .033, η_p² = 0.11]. Specifically, this tDCS protocol optimized information processing efficiency [F(1,39) = 4.43, p = .042, η_p² = 0.10], and the optimization showed a trend to be associated with enhanced rsFC in the right medial prefrontal cortex (ρ = 0.339, pFDR = .083).ConclusionMultisession tDCS with left dlPFC cathode placement and right supraorbital region anode placement paired with concurrent cognitive remediation training promoted social functioning in individuals with ASD. This appeared to be associated with the enhancement of the functional connectivity of the right medial PFC, a major hub for flexible social information processing, allowing these individuals to process information more efficiently in response to different social situations.Trial registrationClinicalTrials.gov (ID: NCT03814083)     

Rasagiline-associated motor improvement in PD occurs without worsening of cognitive and behavioral symptoms

BACKGROUND: Cognitive and behavioral adverse events (AEs) such as hallucinations, confusion, depression, somnolence and other sleep disorders commonly limit effective management of motor symptoms in PD. Rasagiline (N-propargyl-1(R)-aminoindan) mesylate is a novel, second-generation, selective, irreversible monoamine oxidase type B inhibitor, demonstrated in monotherapy and adjunctive trials to be effective for PD with excellent tolerability. METHODS: The occurrence of cognitive and behavioral AEs and the change from baseline in the Unified Parkinson's Disease Rating Scale (UPDRS) part I mental subscores were reviewed in two multicenter, randomized, placebo-controlled, 26-week trials of rasagiline for early and moderate-to-advanced patients with PD. The UPDRS is a multi-item rating scale specific to PD; part I rates the patient's intellectual impairment, thought disorders, depression and motivation/initiative. RESULTS: The TEMPO study evaluated rasagiline monotherapy in early PD patients (n=404). The PRESTO study evaluated rasagiline as adjunctive therapy in moderate-to-advanced PD patients with motor complications who were receiving optimized levodopa/carbidopa (n=472). In the analysis of adverse event reporting for both studies, no cognitive and behavioral AE in either the rasagiline 1 mg or placebo groups exceeded 10% of the study population and the frequency differences between rasagiline 1 mg and placebo never exceeded 3%. There was no adverse effect on the UPDRS mental subscore relative to placebo in either of the two studies. CONCLUSION: Rasagiline 1 mg once daily improves PD symptoms and motor fluctuations in early and moderate-to-advanced PD patients without causing significant cognitive and behavioral AE or adverse changes in mentation, behavior and mood.     

Intensive cognitive-behavioral group treatment (CBGT) of social phobia: a randomized controlled study

The effects of intensive cognitive-behavioral group treatment (CBGT) for social phobia (DSM-IV) were studied in 26 patients randomly assigned either to a treatment group (TG) or to a 6-month waiting list control group (WG). Treatment involved 2 weeks of daily treatment sessions separated by 1 week of homework assignments. TG was superior to WG at all assessment points, i.e., at 3 weeks and at 3 and 6 months of post-treatment. After 6 months, significant treatment effects were found in the majority of social phobia measures indicating decreased levels of social anxiety and avoidance, safety-behaviors and symptoms influence on daily life. The WG received treatment following the waiting list period and was combined with the TG in order to evaluate the outcome in a larger sample. Treatment gains at 3 weeks were maintained or improved at 1-year follow-up. Average effect sizes of social phobia measures ranged from 0.56 at post-treatment, 0.68 at 3 months and 0.81 at 6 months and 1 year, respectively.