The reliability and diagnostic validity of the physical and neurological examination for soft signs (PANESS)

Twenty-one children, mean age of 8 years, were each examined on separate occasions by two pediatric residents, blind to diagnosis, using the neurological examination (PANESS) included in the group of instruments recommended by the National Institute of Mental Health for psychotropic drug studies in children. Half the children were hyperactive/aggressive, one quarter were normal, and one quarter had histories or signs strongly presumptive of brain damage. Many of the signs, though reliable, did not occur in the majority of children. Examiners did achieve a high level of agreement about global neurological status. It was concluded that the neurological examination probably contains a substantial number of non-contributory items and should be regarded as experimental rather than definitive.This study was supported in part by a grant to Professor Werry from the Medical Research Council of New Zealand and USPHS grant #MH 18909 from the National Institute of Health to R. L. Sprague, Ph.D. Drs. M. Hudson and M. Morris performed the examinations. We should like to pay particular tribute to Dr. Thelma Becroft, a school doctor in Auckland, who supplied the normal and neurological subjects.     

Neuropsychological studies of auditory-visual fusion illusions. Four case studies and their implications.

A heard speech sound which is not the same as the synchronized speech sound can sometimes give rise to an illusory phonological percept. Typically, a heard /ba/ combines with a seen /ga/ to give the impression that /da/ has been heard (McGurk, H. and MacDonald, J. Nature Lond. 264, 746-748, 1976). We report the susceptibility to this illusion of four individuals with localized brain lesions affecting perceptual function. We compare their performance to that of ten control subjects and relate these findings to the efficiency of processing seen and heard speech in separate and combined modalities. The pattern of performance strongly suggests LH specialization for the phonological integration of seen and heard speech. The putative site of such integration can be effectively isolated from unilateral and from bilateral inputs and may be driven by either modality.     

Clinical problem solving and the biopsychosocial model.

Engel's biopsychosocial model, while unifying the sciences relevant to medicine under general systems theory, is of limited utility in organizing bedside clinical problem solving. The authors consider this issue in light of the structure and goals of the clinical encounter. The biopsychosocial model is a model for organizing the sciences relevant to medicine; however, medical/psychiatric practice poses problems both within and outside the scientific realm. Since the biopsychosocial model cannot account for clinical problems to which the methods of science do not apply, the authors seek to facilitate biopsychosocial problem solving by proposing a clinical decision-making model that complements the biopsychosocial model. Their model directs the clinician's attention to three core aspects of the clinical encounter: problems of knowledge, ethics, and pragmatics. The authors reconsider Engel's case of Mr. Glover to demonstrate the anticipatory emphasis of the model. Other clinical examples are used to demonstrate the difficulties arising from mistaking one kind of aspect of medicine for another. When these three aspects of medicine are respected equally, a biopsychosocial practice is unavoidable.     

The position of the neurologist in neuro-oncology.

Neuro-oncology is a growing new subspeciality with a strong interdisciplinary character. This position paper explains the role of neurology in the multidisciplinary field of neurosurgeons, radiotherapists and general oncologists, dealing with neuro-oncological patients. The paper delineates the varied spectrum of the field of neuro-oncology which expands from primary brain tumours, to metastatic and non-metastatic effects of systemic cancer on the central and peripheral nervous system, neurotoxicity due to cancer treatment and issues of quality of life. It has been written by the scientific neuro-oncology panel of the European Federation of Neurological Societies (EFNS) to delineate the situation of neuro-oncology in Europe, and facilitate the understanding and implementation of this subspeciality in the future.     

The clinical and diagnostic implications of mosaicism in the neurofibromatoses.

Neurofibromatosis type 1 and type 2 both occur in mosaic forms. Mosaicism results from somatic mutations. Early somatic mutations cause generalized disease, clinically indistinguishable from nonmosaic forms. Later somatic mutation gives rise to localized disease often described as segmental. In individuals with mosaic or localized manifestations of neurofibromatosis type 1 (segmental neurofibromatosis type 1), disease features are limited to the affected area, which varies from a narrow strip to one quadrant and occasionally to one half of the body. Distribution is usually unilateral but can be bilateral, either in a symmetric or asymmetrical arrangement. Patients with localized neurofibromatosis type 2 have disease-related tumors localized to one part of the nervous system; for example a unilateral vestibular schwannoma with ipsilateral meningiomas or multiple schwannomas in one part of the peripheral nervous system. The recognition of mosaic phenotypes is important. Individuals with the mosaic form, even with a generalized phenotype, are less likely to have severe disease. They also have lower offspring recurrence risk than individuals with the nonmosaic form. The mosaic forms of neurofibromatosis provide a good example of the effects of somatic mutation. It is increasingly recognized that mild and unusual forms of many dominantly inherited disorders are caused by the same mechanism.     

The gut microbiome:implications for neurogenesis and neurological diseases

There is an increasing recognition of the strong links between the gut microbiome and the brain,and there is persuasive evidence that the gut microbiome plays a role in a variety of physiological processes in the central nervous system.This review summarizes findings that gut microbial composition alterations are linked to hippocampal neurogenesis,as well as the possible mechanisms of action;the existing literature suggests that microbiota influence neurogenic processes,which can result in neurological disorders.We consider this evidence from the perspectives of neuroinflammation,microbial-derived metabolites,neurotrophins,and neurotransmitters.Based on the existing research,we propose that the administration of probiotics can normalize the gut microbiome.This could therefore also represent a promising treatment strategy to counteract neurological impairment.     

The diagnostic questionnaires and their use in epidemiological studies in psychiatry

The paper presents diagnostic instruments employed in psychiatric; brief history of their development with regard to their importance for progress in psychiatric epidemiology, the characteristic of the most important diagnostic questionnaire (Present State Examination--PSE, Composite International Diagnostic Interview--CIDI, Schedules for Clinical Assessment In Neuropsychiatry--SCAN, Structured Clinical Interview for DSM IV--SCID, Schedule for Affective Disorders and Schizophrenia--SADS, Diagnostic Interview Schedule--DIS). It also describes some features that should be considered while choosing a proper instrument for a given study. The authors call attention to some differences between instruments, e.g., those related to the structure of the questionnaire, involving diagnostic categories, the sort of information that an instrument allows to collect, competence of interviewers and their training, and also population for which the instrument is assigned. Presenting advantages and disadvantages of instruments, the authors emphasize that there is no best instrument. The choice of questionnaire depends, first of all, on the purpose of the study and the funds that the researches have at their disposal.     

Current understanding of the circadian clock and the clinical implications for neurological disorders.

The changes in behavior that occur on a 24-hour basis to match the 24-hour changes in the physical environment due to the rotation of the earth on its axis are a hallmark of life on the planet Earth. The nervous system of both lower and higher organisms has evolved over millions of years to meet the demands of the dramatic changes in the physical environment that occur in relation to the changes in the light-dark cycle, optimizing the survival and reproductive success of the organism. During the past 50 years, it has been clearly established that the 24-hour nature of life was not simply a response to the 24-hour changes in the physical environment imposed by celestial mechanics, but instead was due to an internal time-keeping system in the brain. Many neurological disorders are associated with abnormal 24-hour rhythms, including the sleep-wake cycle. The recent discovery of the molecular basis of the neural clock in animals offers neurologists new avenues for studying the pathophysiology of neurological disorders.     

药物自我治疗技能训练对慢性精神分裂症的效果

目的　探讨药物自我治疗技能训练 (SelfMedicationManagementSkillTraining)对慢性精神分裂症的效果。方法　将 6 8例服用氯氮平治疗的慢性精神分裂症患者随机分为药物自我治疗技能训练组 (简称训练组 )和对照组。训练组患者进行技能训练 ,共 12周。采用临床大体印象量表 (CGI)、简明精神病评定量表 (BPRS)和阴性症状评定量表 (SANS)进行效果评定 ,同时检测氯氮平和去甲氯氮平血浓度、外周血T细胞亚群与白介素Ⅱ受体 (SIL 2R)。结果　训练组患者阴性症状的改善以及免疫因子CD3 + 、CD4+ 和CD4+ /CD8+ 的增高均优于对照组 (P <0 0 5 ) ,且药物自我治疗技能显著提高 (P <0 0 1)。结论　药物自我治疗技能训练有助于慢性精神分裂症的治疗和康复     

What the child neurologist should know at the conclusion of training: history taking, examination, and formulation (and a few other generalizations)

Taking of neurological history, performance of neurological examination, and the employment of these sets of information to properly formulate a neurological question constitute the most fundamantal skills of the neurologist. Intelligent facility with these skills must be required of every child neurologist at the completion of training. They will subsequently be refined upon the basis of experience and wider knowledge of neurology and neuroscience which will improve upon the initial level of facility. There are other habits of mind and approach that must also be expected to have been awakened and refined by the time that formal training has been completed.     

Results of the management of atherothrombosis with clopidogrel in high-risk patients trial: implications for the neurologist

The secondary prevention of ischemic stroke is aided by the use of antiplatelet therapy, and the predominant current choices are aspirin, aspirin plus extended-release dipyridamole, and clopidogrel. The potential utility of combining platelet antiaggregants with different mechanisms of action proved successful with aspirin plus extended-release dipyridamole, and this approach has been explored with the combination of clopidogrel and aspirin. In the Management of Atherothrombosis With Clopidogrel in High-Risk Patients trial, this combination was compared with clopidogrel alone for secondary prevention in patients with transient ischemic attack and stroke in a high-risk population with a high prevalence of other vascular risk factors. A nonsignificant trend for a reduction of the combined endpoint of ischemic stroke, myocardial infarction, vascular death, and rehospitalization was observed in the combination therapy group (P = .24). The frequency of serious, life-threatening bleeding adverse effects was almost doubled in the combination arm. Neurologists need to be aware of these results and avoid the use of clopidogrel plus aspirin in patients with stroke or transient ischemic attack until evidence that the combination is safe in this population is provided. Neurologists faced with patients who have had a stroke or transient ischemic attack and are receiving this combination of antiplatelet agents after coronary stenting should inform their cardiology colleagues of the reported bleeding risk, and they should encourage the use of the combination for as short a time period as possible after such coronary intervention.