A Double-Blind Controlled Study of Clinical Efficacy of Maprotiline and Amitriptyline in Depression

A multiclinic double-blind controlled study was performed on the effects of MAP in both inpatients and outpatients with AMT as control drug.

• 1 Subjects consisted of 41 male and 45 female patients suffering from various types of depression. MAP was assigned to 42 cases and AMT to 44 cases. Of these patients, 14 MAP cases and 10 AMT cases were subsequently dropped for a variety of reasons to obtain 28 MAP cases and 34 AMT cases as evaluable.
• 2 The global improvement ratings were compared and found not significantly different for any week between the two treatments.
• 3 The global improvement ratings by the characteristic features of patients did not show any significant difference in any items studied between the two treatments.
• 4 The symptomatic improvement ratings (on the Hamilton R.S. for assessment by the physician) indicated that AMT was more effective on “anxiety (psychic).”
• 5 The symptomatic improvement ratings (on the Beck self-assessment scale by the patient) indicated that MAP was more effective on “work” and AMT on “pathos”, “feeling of satisfaction”, “withdrawal” and “loss of libido.”
• 6 During the treatment period, 74.3 percent of the MAP group and 76.9 percent of the AMT group of patients showed some side effects or accompanying symptoms, with no significant difference recognized between the two treatments. Itemwise, however, the incidence of tremor was significantly lower (p-=0.06) in the MAP group. Moreover, the MAP group tended to be less liable to such anti-cholinergic side effects as dry mouth, constipation, trouble of accommodation, urinary disturbance and palpitation.
• 7 On the basis of the above findings, it is concluded that MAP is as effective against depression as AMT and less liable to the anticholinergic side effects. It is, therefore, a very useful antidepressant.

     

Effect of 7-Bromo-5-(2-pyridyl)-3H-l, 4-benzodiazepine-2(1H)-one, Bromazepam (Ro 5–3350), a New Minor Tranquilizer, on Psychoneurosis with Special Reference to the Obsessive-Compulsive Symptoms

Clinical application of a minor tranquilizer bromazepam, 7-Bromo-5-(2-pyridyl)-3H-1,4-benzodiazepine-2(lH)-one (Ro 5–3350) was made on 18 cases of obsessive-compulsive neurosis, 10 of anxiety neurosis, 6 hypochondriasis, 4 hysteria and 3 of phobia of bodily odor.

• 1) In 18 cases of obsessive-compulsive neurosis, bromazepam was found markedly effective in 6, effective in 3, fairly effective in 5, ineffective in 2, and aggravated in 2 cases. The effective cases were those with obsessive thinking and manifest anxiety. In other kind of neurosis, bromazepam was markedly effective in 5 and effective in 2 of 10 anxiety neurotic cases, whereas it was almost ineffective in the cases of hypochondriasis, hysteria and phobia of bodily odor.
• 3) The maximum daily dose of bromazepam was 10 to 20 mg in many cases, and 20 to 30 mg in some other cases. The durg is quick-acting to such an extent that it took 2 to 5 days for its action to become manifest in markedly effective cases.
• 4) Various laboratory tests revealed no appreciable abnormality in most cases where bromazepam was employed. Physical side effects such as slight hypotension, dizziness, and sleepiness were observed in a few cases, and mental side effects such as loquaciousness and restlessness in about 20 cases.
• 5) The target symptoms of bromazepam were suggested to be anxiety, tension, and irritation like previously reported other benzodiazepines. The fact that its action of relieving anxiety and tension and of elevating mood was found to be more potent than those of other benzodiazepines and that it was effective on some obsessive-compulsive neurosis that showed little response to other benzodiazepines, suggested that bromazepam is a potent and characteristic new minor tranquilizer of clinical value.

     

Clinical Features of Autistic Children with Setback Course in Their Infancy

Abstract: This study examines the incidence rate of setback in 80 autistic children, the correlation between the type of onset and clinical features, developmental level and prognosis based on an originally developed questionnaire. Moreover, this study seeks to investigate the possibility that infantile autism might be classified into subgroups by the type of onset.

• 1) The acquired (including questionably acquired) group consisted of 39 cases (49%), while the natal group was made up of 41 cases (51%).
• 2) The age when the setback occurred was 21–22 months in the acquired group.
• 3) Precipitating psychological events were observed in 22 cases (56%) of the acquired group.
• 4) The mental developmental level including speech and sociability function at 5 years of age was significantly lower in the acquired group than in the natal group.
• 5) The acquired group showed severe behavioral disorderssuch as “stereotypic behavior,”“extremely hyperkinetic behavior” and “self-abusive behavior” compared with the natal group.
• 6) The adaptive levels at schools or institutions were lower in the acquired group than in the natal group.
• 7) There was a higher incidence of epileptic seizures orfebrile convulsions in the acquired group than in the natal group. Moreover, there was a higher incidence of severe perinatal abnormalities in the acquired group.
• 8) The above-mentioned results suggest that infantile autism might be classified into two subgroups, acquired and natal groups, based on the typeof onset, and also suggest that some types of brain dysfunctions are more severe in the acquired group than in the natal group.

     

Affective dimensions as a diagnostic tool for bipolar disorder in first psychotic episodes

ObjectiveTo examine the predictive diagnostic value of affective symptomatology in a first-episode psychosis (FEP) sample with 5 years’ follow-up.MethodAffective dimensions (depressive, manic, activation, dysphoric) were measured at baseline and 5 years in 112 FEP patients based on a factor structure analysis using the Young Mania Rating Scale and Hamilton Depression Rating Scale. Patients were classified as having a diagnosis of bipolar disorder at baseline (BDi), bipolar disorder at 5 years (BDf), or “other psychosis”. The ability of affective dimensions to discriminate between these diagnostic groups and to predict a bipolar disorder diagnosis was analysed.ResultsManic dimension score was higher in BDi vs. BDf, and both groups had higher manic and activation scores vs. “other psychosis”. Activation dimension predicted a bipolar diagnosis at 5 years (odds ratio = 1.383; 95% confidence interval, 1.205–1.587; P = 0.000), and showed high levels of sensitivity (86.2%), specificity (71.7%), positive (57.8%) and negative predictive value (90.5%). Absence of the manic dimension and presence of the depressive dimension were both significant predictors of an early misdiagnosis.ConclusionThe activation dimension is a diagnostic predictor for bipolar disorder in FEP. The manic dimension contributes to a bipolar diagnosis and its absence can lead to early misdiagnosis.     

First admissions for mood disorders in immigrants to the Netherlands

BACKGROUND: The risk of developing schizophrenia is increased for immigrants to the Netherlands from Surinam, the Netherlands Antilles and Morocco, but not for immigrants from Turkey. We examined, in these groups, the risks of a first admission for manic-depressive psychosis. METHODS: The Dutch Psychiatric Registry provided two datasets. The first referred to first admissions for manic-depressive psychosis (MDP), manic or circular type, in the period 1990-1996, the second to first admissions for MDP, depressed type. MDP, depressed type, corresponds (broadly) to the DSM-IV category of major depressive disorder and MDP, manic or circular type, to the DSM-IV category of bipolar I disorder. The Dutch Central Bureau for Statistics provided yearly population figures. RESULTS: There were only small increases in the risks of a first admission for MDP, manic or circular type, for immigrants from Surinam (age- and sex-adjusted RR = 1.14; 95% CI: 0.97-1.33) and the Netherlands Antilles (RR = 1.41; 1.10-1.80). This risk was not clearly increased for immigrants from Morocco. The risks for MDP, depressed type, were increased for males from Morocco (age-adjusted RR = 2.17; 1.72-2.72) and Turkey (RR = 1.83; 1.46-2.30), and significantly decreased for females in all of the immigrant groups. CONCLUSION: We found no evidence for a large increase in the incidence of MDP, manic or circular type, in the immigrant groups, whereas an increase in MDP, depressed type, was observed only in selected groups. Female immigrants suffering from MDP, depressed type, may be underserved.     

STUDIES ON 'INNER SPEECH' PART II: HEARING AND SPEECH MOVEMENT

• 1) Considering excellent faculties of a few deaf children in language, the verval defect of congenital aphasiacs in some cases at least–may be due to motoric dysfunction and not to auditory imperfection.
• 2) A boy of “congenital aphasia” can not hear voices distinguishably which he can not arculate distinctively.
• 3) Motor aphasic patients often mishear others' voices whose articulation (or pronunciation) is like each other.
• 4) Aphasiacs are trying to comprehend the word not by auditory sensation of every syllable but by the general effect of the words.
• 5) The hearing of aphasiacs is markedly disturbed by artificial noises.
• 6) Aphasiacs and congenital aphasiac boys have poor auditory successive memory of voices even if their perception is correct, just as they have poor visual successive memory of letters.
• 7) It is supposed that aphasiacs perceive voices by auditory perception alone, and that normal adults transform voices into patterns of speech, in order to make auditory perception accurately and, in addition, keep this accuracy up.

     

On Early and Mid-Adolescent Schizophrenia Part1: Phenomenological Aspects

One hundred and seventy-three early and mid-adolescent schizophrenic patients were investigated during the 18-year period from April 1958 to March 1976 and the results concerning phenomenological aspects were reported here along with some considerations.

• 1 Hereditary predispositions were found in 43 cases among 161 patients. Male patients seemed to be more predisposed than female patients. The incidence of schizophrenia was the highest among other mental disorders, while it was most frequently observed in mothers and siblings among other kinships.
• 2 Precipitative factors were recognized in 45 cases. Among them, primary social factors and physical conditions seemed to play a rather important role. These factors seemed more frequent in males than in females.
• 3 As to birth order, the incidence of adolescent schizophrenia seemed to be higher in the last half of sibships than in the first half but the difference was significant at a five-percent level when the sibship sizes were 5–9. From the comparison of our results with the national statistics of the birth order in general population, the incidence of adolescent schizophrenia seemed to be lowest in the siblings of the second birth.
• 4 We divided the onset into three types; acute, intermediate and insidious. We were imlpressed that the acute onset seemed gradually to increase in mid-adolescence and the insidious onset vice versa. In addition, the insidious onset was found chiefly in cases with hebephrenic pictures except hebe-paranoid.
• 5 Hebephrenic form and simple form were frequently observed but catatonic form was relatively few. Genuine paranoid form was not found in our materials. Hebephrenic and catatonic forms were more frequently seen in males, while hebeparanoid form was more frequent in females.
• 6 Main symptoms at the onset were discussed. Delusional activities, still vague and fragmentary, were observed in about half of our materials, being mostly persecutory. It seemed that they were strongly influenced by the state of mood of patients. Hallucinations, mostly auditory of verbal nature, were observed in more than one-fourth of our patients. On the contrary, the cases with visual and bodily hallucinations were a few in number.

Autistic tendency and refusal of scholastic activities were more frequently seen in early adolescence, while suicidal attemlpts or self-injuring tendency, manic or depressive tinge, “gemachte Erlebnisse”, “Eigengeruchsparanoia” were rather prevalent or first observed in mid-adolescence. Various symptoms, in general, seemed to become gradually more prominent along with the progression of ages.

• 7 EEG findings and treatment were reported at the same time. But the course and the problem of defect will be dicussed in another paper.
• 8 Finally, the summaries of sex differences and of the comparison between early and mid-adolescence were supplemented.

     

A Long-Term Clinical Course of Psychomotor Epilepsy (I)

A comparative study of clinical features and outcome was undertaken in 21 epileptic patients, five suffering from isolated psy-chomotor seizure without generalized convulsion (Group A), seven suffering from psychomotor seizure combined with generalized convulsion, from which complication they have been freed for over five years (Group B), and nine suffering from psychomotor seizure combined with continued generalized convulsion (Group C). These patients were over 10 years old at onset and have been followed up for 10 to 19 years at the Department of Neuropsychiatry of the Kansai Medical University Hospital. The seizure components in the long-term courses of these three groups were classified as they are under the heading of “partial seizures with complex symptomatology” in the “Clinical and Electroencephalographid Classification of Epileptic Seizures” proposed by the International League Against Epilepsy.

• 1 The nature of the seizures is monotonous and little varied in Group A and quite varied in Groups B and C. It seems to be a significant difference between isolated group and combined one regarding partial seizures with cognitive symptomatology. Partial seizures with dysmnesic disturbances seem to be closely related to the presence of generalized convulsion.
• 2 The contents of forced thinking tend to remain the same from one seizure to another in the isolated group, while they differ considerably in the combined one. In the strict sense, forced thinking differs from obsessive idea and is rather similar to autochthonous idea.
• 3 Episodic moodiness during seizure intervals is more clearly seen in the isolated group than in the combined one, but this tendency is also obvious in Group B.
• 4 Episodic psychotic state appears much more frequently in the combined groups than in the isolated one, and it appears on an average of 14 years of the course.
• 5 Deterioration in basic EEG rhythm is seen in a majority of cases, most of which belong to the combined group. Change in basic EEG rhythm is not seen in patients freed from generalized convulsion particularly in whom it has disappeared early.
• 6 In long-term clinical courses lasting more than 10 years, the disappearance of generalized convulsion leads to the disappearance or diminution of automatisms, but it also leads to the appearance or augmentation of autonomic seizure and affective seizure. Forced thinking tends to be perceptive and to develop to hallucinatory delusional experience through its repeated appearance over a long period of time.
• 7 As to outcome, all the isolated psychomotor cases improved, while half the combined cases showed no change or became worse. The prognosis for cases with continuous generalized convulsion is bad.

These findings suggest that many of the symptoms in patients with psychomotor seizures are closely connected with the presence of generalized convulsion.     

A study on attentional bias and response inhibition of facial expressions in manic patients: evidence from eye movement

Abstract

Introduction: In recent years, evidence has accumulated to suggest that patients with bipolar disorder show altered processing of emotionally relevant information. However, only a few studies have examined manic patients’ eye movements when processing facial expressions.

Method: A free viewing task and anti-saccade task were used separately to investigate attentional bias and response inhibition while processing emotional stimuli. Data were drawn from matched samples of manic patients (n?=?25) and healthy controls (n?=?20).

Results: The analyses of eye-movement data revealed that there was a significant difference between manic patients and healthy controls in the total duration of fixations but not in the orientation or duration of the first fixation. However, no significant differences between manic patients and healthy controls in response inhibition were detected.

Conclusion: These results demonstrate that compared to healthy controls, manic patients show a deficiency in processing speed. The patients showed no attentional vigilance to happy or sad expressions but did showed avoidance of the sad expression and focused more on the happy expression in later emotion processing. There were no impairments of response inhibition detected in manic patients.

• Key points

• Abnormal processing of emotional information and having aberrant inner-experiences of emotion is a feature of bipolar disorders.

• Processing speed is slow in manic patients versus healthy controls.

• Manic patients focused lesser on sad expression than healthy controls, which suggesting an avoidance of sad expressions.

• The findings show that psychotherapies like CBT may be applicable to manic patients.

     

Prognosis of the Lennox Syndrome—Long-Term Clinical and Electroencephalographic Follow-up Study, Especially with Special Reference to Relationship with the West Syndrome

The long-term clinical and electroencepha-lographic follow-up studies were carried out for more than three years, up to 14 years in the longest, on 116 cases with Lennox syndrome. And the results of systematic study on changing patterns and outcome have been reported. The follow-up examination was performed also on West syndrome which is closely related with Lennox syndrome; especially the relationship between both syndromes regarding prognosis has been clarified.

• 1 According to the long-term follow-up on 116 cases with Lennox syndrome, there were 98 cases (84.5%) having mental defect. The remaining of seizure was observed in 71 cases (61.2%) and persisted as Lennox syndrome except for one case.
• 2 Generally speaking, the cases with age of onset before two years old showed unfavorable outcome.
• 3 There were 42 cases (36.2%), which were converted from West syndrome and showed markedly unfavorable prognosis in regard to intelligence as well as the remaining of seizure. (31 cases, 77.5%)
• 4 On the other hand, in 23 idiopathic cases, which showed no developmental retardation before onset of seizure, had favorable outcome, and the remaining of seizure was observed in eight cases (34.8%). However, even in such cases, it was noticed that those displaying mental defect at the follow-up attained 14 cases (60.9%). That is to say, it was clarified that persistence of even minor seizures induced mental deterioration.
• 5 The cases with favorable prognosis showed usually a typical slow spike-and-wave pattern electroencephalographically, whereas those with poor prognosis showed mostly an asymmetric or disorganized slow spike-and-wave pattern.
• 6 In many cases displaying signs of brain atrophy with pneumoencephalogram and accompanying overt neurological signs at the initial examination, prognosis is obviously poor.
• 7 From the follow-up examination on 94 cases with West syndrome for three to 15 years, there were 51 cases (54.3%) which was transformed into Lennox syndrome. Among them, those cases with the remaining of seizure at the time of follow-up were 44 (46.8%) out of 94 cases, of which 37 cases (83.8%) had remaining seizure as Lennox syndrome.
• 8 From the above results, it is emphasized that Lennox and West syndromes show close relationship with each other and that a study should be done on the interrelation between their prognosis.

     

Therapist effectiveness: Implications for accountability and patient care

Abstract

Significant therapist variability has been demonstrated in both psychotherapy outcomes and process (e.g., the working alliance). In an attempt to provide prevalence estimates of “effective” and “harmful” therapists, the outcomes of 6960 patients seen by 696 therapists in the context of naturalistic treatment were analyzed across multiple symptom and functioning domains. Therapists were defined based on whether their average client reliably improved, worsened, or neither improved nor worsened. Results varied by domain with the widespread pervasiveness of unclassifiable/ineffective and harmful therapists ranging from 33 to 65%. Harmful therapists demonstrated large, negative treatment effect sizes (d=?0.91 to ?1.49) while effective therapists demonstrated large, positive treatment effect sizes (d=1.00 to 1.52). Therapist domain-specific effectiveness correlated poorly across domains, suggesting that therapist competencies may be domain or disorder specific, rather than reflecting a core attribute or underlying therapeutic skill construct. Public policy and clinical implications of these findings are discussed, including the importance of integrating benchmarked outcome measurement into both routine care and training.     

Lithium and suicide prevention in bipolar disorder

IntroductionBipolar disorder (BD) is a severe and recurrent psychiatric disorder. The severity of prognosis in BD is mainly linked to the high rate of suicide in this population. Indeed, patients with BD commit suicide 20 to 30 times more frequently than the general population, and half of the BD population with an early age of onset have a history of suicide attempt. International therapeutic guidelines recommend lithium (Li) as the first-line treatment in BD for its prophylactic action on depressive or manic episodes. In addition, Li is the only mood stabilizer that has demonstrated efficacy in suicide prevention. This effect of Li is unfortunately often unknown to psychiatrists. Thus, this review aims to highlight evidence about the preventive action of Li on suicide in BD populations.MethodsWe conducted a literature search between April 1968 and August 2014 in PubMed database using the following terms: “lithium” AND “suicide” OR “suicidality” OR “suicide attempt”.ResultsAs confirmed by a recent meta-analysis, many studies show that Li has a significant effect on the reduction of suicide attempts and deaths by suicide in comparison to antidepressants or other mood-stabilisers in BD populations. Studies have demonstrated that long-term treatment with Li reduces suicide attempts by about 10% and deaths by suicide by about 20%. The combination of Li and an antidepressant could reduce suicidal behaviours by reducing suicidal ideation prior to depressive symptoms. It appears crucial for Li efficacy in suicide prevention to maintain the Li blood concentrations in the efficient therapeutic zone and to instate long-term Li treatment. The “impulsive-aggressive” endophenotype is associated with suicide in BD. The specific action of Li on the 5-HT serotoninergic system could explain the specific anti-suicidal effects of Li via the modulation of impulsiveness and aggressiveness. Furthermore, genetic variants of the glycogen synthase kinase 3α/β (GSK3α and β; proteins inhibited by Li) seem to be associated with more impulsiveness in BD populations.ConclusionThe anti-suicidal effect of Li has been very well demonstrated. By its specific action on the serotoninergic system, treatment with Li significantly reduces “impulsive-aggressive” behaviour which is a vulnerability factor common to suicide and BD. Long-term appropriately modulated treatment with Li seems to have considerable impact on the reduction of suicidal behaviours, suicidal ideation and death by suicide in the BD population.     

Effects of piracetam on the performance of rats in a delayed match-to-position task

• 1.1. The influence of acute and chronic treatment with piracetam on spatial working memory of rats was examined. A new version of an operant chamber “delayed match-to-position task” was used, in which the animals had to visit one randomly baited box out of three boxes (“choice boxes”) in a front panel. Hereafter a delay period began, in which the subjects had to visit an alcove in the back panel (“reference box”). At the end of the delay the animals should return to the front panel and choose the same choice box that was baited before the delay, thereby obtaining a reward.
• 2.2. Rats were trained to a stable level of performance, measured as per cent correct responses during sessions of 20 trials. Additionally, the time spent between leaving the choice box and entering the reference box was recorded. Results were obtained from a single group of rats tested repeatedly under different experimental conditions.
• 3.3. Injections of scopolamine (0.6 mg/kg) significantly reduced the percentage of correct choices and increased the time spent to reach the reference box. The impairment of correct choices was reversed after chronic treatment with piracetam (250 mg/kg). However, the same treatment did not reverse the effect of scopolamine on the time performance.
• 4.4. Scopolamine also induced an increase of repetitive errors (a measure of perseverance), and the chronic treatment with piracetam caused full reversal of this increase. These results represent the first observation of a piracetam induced reversal of scopolamine impairments in a working memory test.
• 5.5. In normal animals not treated with scopolamine, acute injection of piracetam had no effect compared to saline injected controls, but chronic treatment with the nootropic significantly enhanced working memory performance. The drug did not affect the time used to reach the reference box.
• 6.6. The resulting data suggest that piracetam has distinct effects on working memory depending on the mode of treatment (acute versus chronic).

     

Statistical Analysis of Multiple Sclerosis and Neuromyelitis Optica Based on Autopsied Cases in Japan*

• 1 40 autopsied cases of demyelinating diseases in Japan were classified, based on autopsy findings, into three groups; 18 cases of multiple sclerosis (MS) group, 13 cases of neuromyelitis optica (NMO) group and 9 cases of intermediate form.
• 2 The clinical features were compared in the MS and NMO groups by Chi square test.
• 3 By “component analysis”, it was shown that the MS and NMO groups could be discriminated clinically with high reliability.
• 4 In the component analysis, disturbance of consciousness, emotional disturbance, bulbar signs and incoordination were the significant items for the MS group, and onset with fever or infection, bilateral simultaneous visual impairment and infection in the past history for the NMO group.
• 5 (5) The component analysis was proved to be applicable in the clinical differentiation of MS and NMO.

     

SUCCESSIVE MEASUREMENTS OF URINARY 5-HIAA IN MENTAL ILLNESS WITH SPECIAL REFERENCE TO DIURNAL CHANGES AND LOADING TEST WITH TETRABENAZINE

• 1) Successive measurement of 5-HIAA excretion in relation to changes in the clinical condition revealed a tendency to a relative increase during the state of impaired consciousness, emotional disturbance or psychomotor restlessness.
• 2) Diurnal variations of 5-HIAA levels in 3 hour urine fractions were the greatest in acute psychotics followed by organic psychotics, chronic schizophrenics and controls. Acute psychotics tended to stabilize with clinical improvement, but still were relatively unstable even in states of near remission. In the chronic schizophrenic group, variation was relatively small, about the same as in the control group.
• 3) No significant difference was demonstrated between the chronic schizophrenic and control groups in terms of the increase response of the 5-HIAA level after L-tryptophan loading.
• 4) Loading of tetrabenazine resulted in maximum release of 5-HIAA within 9 hours and recovery to the initial level in 18 hours in the control group, while abnormal responses were seen in the three groups of psychotics, as follows;

• a) In the chronic schizophrenic group, the maximum level of 5-HIAA was reached more slowly and the recovery time prolonged (“delayed and probnged response”).
• b) In the acute psychotic group, 5-HIAA level was very high and recovered very rapidly (“excessive response”).
• c) In the organic psychotic group, increase of 5-HIAA level was more or less similar to that of the contro? group, but recovery tended to be delayed (“prolonged response”).

     

A Morphological Study on Vascular Changes in the Surgically Resected Tissues of Temporal Lobe Epilepsy—with a Special Reference to the Etiology

• 1 Twenty-one out of 23 cases surgically resected specimens of TLE presented the common histological findings; sclerotic changes of the tissues. And the other two cases encountered the small tumors which might be called “cryptic.”
• 2 Since circulatory disturbance is generally accepted to explain the cause of TLE, we reexamined vascular behaviors in detail and found the quantitative and qualitative abnormalities which reached the high rate of 71% (17 out of 21 cases) except two cases of small tumors. Moreover, it is remarkably noteworthy that these vascular changes adjoin the sclerosed parenchymal tissue.
• 3 It may be said that vascular changes have exerted some influences on the formation of inferomedial temporal sclerosis from the standpoint of the histological findings, though they are alone not fully sufficient to explain the etiology of TLE.

     

A standardized nomenclature for spectrogram EEG patterns: Inter-rater agreement and correspondence with common intensive care unit EEG patterns

ObjectiveTo determine the inter-rater agreement (IRA) of a standardized nomenclature for EEG spectrogram patterns, and to estimate the probability distribution of ictal-interictal continuum (IIC) patterns vs. other EEG patterns within each category in this nomenclature.MethodsWe defined seven spectrogram categories: “Solid Flames”, “Irregular Flames”, “Broadband-monotonous”, “Narrowband-monotonous”, “Stripes”, “Low power”, and “Artifact”. Ten electroencephalographers scored 115 spectrograms and the corresponding raw EEG samples. Gwet's agreement coefficient was used to calculate IRA.ResultsSolid Flames represented seizures or IIC patterns 69.4% of the time. Irregular Flames represented seizures or IIC patterns 38.7% of the time. Broadband-monotonous primarily corresponded with seizures or IIC (54.3%) and Narrowband-monotonous with focal or generalized slowing (43.8%). Stripes were associated with burst-suppression (37.2%) and generalized suppression (34.4%). Low Power category was associated with generalized suppression (94%). There was “near perfect” agreement for Solid Flames (κ = 94.36), Low power (κ = 92.61), and Artifact (κ = 93.72). There was “substantial agreement” for all other categories (κ = 74.65–79.49).ConclusionsThis EEG spectrogram nomenclature has high IRA among electroencephalographers.SignificanceThe nomenclature can be a useful tool for EEG screening. Future studies are needed to determine if using this nomenclature shortens time to IIC identification, and how best to use it in practice to reduce time to intervention.     

Lithium prophylaxis: a critical review

The prophylactic use of lithium had its origin in 1963 when Hartigan reported that maintenance doses of lithium carbonate were effective in preventing recurrence of manic and depressive episodes in patients with a history of frequent attacks.¹ This was followed by similar reports by Baastrup² and Baastrup and Schou.³ The latter investigators reported that “lithium is the first drug demonstrated as a clear-cut prophylactic agent against one of the major psychoses.”³ Prophylaxis in psychiatry is a unique concept, and it is not surprising that this claim aroused considerable interest and skepticism.Each of the aforementioned studies were longitudinal trials that compared frequency and severity of episodes during lithium therapy with frequency and severity during an equivalent period before lithium therapy. These studies were severely criticized on methodological grounds,^4–6 and lithium prophylaxis became a subject of international controversy. The critics contended that the issue of lithium prophylaxis could not be resolved by longitudinal trials and stressed the need for comparisons with placebo and control medication. Subsequently, there had been several comparisons of lithium with placebo and a few with imipramine. Because these studies are of key importance in the evaluation of lithium prophylaxis, they will be discussed individually.     

Febrile seizures and genetic epilepsy with febrile seizures plus (GEFS+)

Aim. To review the literature about febrile seizures and GEFS plus with special emphasis on management and outcome. Methods. Selected literature review. Results. Febrile seizures are the most common convulsive event in humans, occurring in 2–6% of the population. The aetiology is complex with strong evidence for a heterogeneous genetic predisposition interacting with fever of any cause, with certain viral infections having a greater effect. A large amount of literature has established that febrile seizures have no long‐term consequences on cognition or behaviour. Unfortunately, about 40% of children with a first febrile seizure will have a recurrence. The strongest predictor of recurrence is age <14–16 months at the time of the first febrile seizure. Epilepsy follows febrile seizures in ～3% cases, with the concepts of simple and complex febrile seizures providing relatively weak prediction. Very prolonged febrile seizures may lead to mesial temporal sclerosis and temporal lobe epilepsy although the degree of risk remains uncertain. Investigations beyond establishing the cause of the provoking fever are nearly always unnecessary. Treatment is mainly reassurance and there is some evidence that parents eventually “come to grips” with the fear that their children are dying during a febrile seizure. Antipyretic medications are remarkably ineffective to prevent recurrences. Daily and intermittent prophylactic medications are ineffective or have unacceptable side effects or risks. “Rescue” benzodiazepines may prevent prolonged recurrences for selected patients with a first prolonged febrile seizure although this has not been proven. Genetic epilepsy with febrile seizures plus (GEFS+) is a complex autosomal dominant disorder usually caused by mutations in SCN1A (a voltage‐gated sodium channel). One third of patients have febrile seizures only; two thirds have a variety of epilepsy syndromes, both focal and generalized. Conclusions. Febrile seizures may distress parents but rarely have any long‐term consequences. Reassurance is the only treatment for the vast majority. Identifying patients with GEFS plus may lead to further investigations and counselling.     

Increased incidence of axonal Guillain‐Barré syndrome in La Spezia area of Italy: A 13‐year follow‐up study

Guillain‐Barré syndrome (GBS) is an acute immune‐mediated polyradiculoneuropathy with a worldwide incidence of 0.81‐1.89 per 100 000 person‐years. In Europe and North America only 5% of patients with GBS have axonal subtypes, which in South America and Asia account for 30%‐47% of cases. The aim of our study is to assess the annual incidence and clinical features of GBS in La Spezia area in Italy. A retrospective (from 1 January 2003 to 31 December 2011) followed by a prospective (from 1 January 2012 to 31 December 2015) analysis was carried out on patients admitted to La Spezia hospital who fulfilled the GBS diagnostic criteria. A total of 86 patients (58 men), mean age of 62.7 years (range 21‐90), were included. The mean annual incidence rate was 3/100 000 (range: 0.9/100 000‐5.37/100 000) significantly higher than the European incidence (P < 0.001). Forty‐seven percent were classified as acute inflammatory demyelinating polyradiculoneuropathy (AIDP), 35% as acute motor and motor‐sensory axonal neuropathy (AMAN‐AMSAN), 13% as variant forms, and 5% were not defined. AIDP was most common in “Golfo dei Poeti” (50%) and “Val di Magra” (63.2%), whereas AMAN/AMSAN prevailed in “Val di Vara” (63.6%) and “Riviera Spezzina” (62.5%) (P = 0.024). In La Spezia area GBS incidence (especially the AMAN subtype) is significantly higher than the incidence reported in Europe. AIDP predominates in the eastern area whereas AMAN/AMSAN in the western, with a significantly different incidence rate (P = 0.003). Prospective studies to assess possible predisposing environmental factors are needed.