Pediatric stroke: what do we know and what do we need to know?

Stroke is a heterogeneous disorder and an important cause of mortality and chronic morbidity in children. Estimates of international incidence rates for childhood stroke have varied widely. Arterial ischemic stroke is reported to be more common than hemorrhagic stroke in children. The clinical presentation of stroke in children differs according to the child's age and stroke type and location. Several risk factors for ischemic and hemorrhagic stroke in children have been reported and include cardiac disorders, blood disorders, vasculopathies, viral infections, and arteriovenous malformations. Current treatment recommendations for stroke in children are based on small nonrandomized trials, adult stroke studies, case series, or consensus or individual expert opinion. Over half of children with stroke will develop lifelong cognitive or motor disability, and up to a third will have a recurrent stroke. International studies have provided important information on stroke in children, but major gaps in our knowledge of the disorder still exist. Currently, there is a need for prospective cohort studies in diverse populations, which utilize a consensus pediatric stroke classification system and a standard evaluation of risk factors and outcome, so that treatment and prevention strategies can be developed.     

Sleep deprivation in depression: what do we know, where do we go?

Manipulations of the sleep-wake cycle, whether of duration (total or partial sleep deprivation [SD]) or timing (partial SD, phase advance), have profound and rapid effects on depressed mood in 60% of all diagnostic subgroups of affective disorders. Relapse after recovery sleep is less when patients are receiving medication; it may be prevented by co-administration of lithium, pindolol, serotonergic antidepressants, bright light, or a subsequent phase advance procedure. Diurnal and day-to-day mood variability predict both short-term response to SD and long-term response to antidepressant drug treatment. These mood patterns can be understood in terms of a "two-process model of mood regulation" based on the model well established for sleep regulation: the interaction of circadian and homeostatic processes. The therapeutic effect of SD is postulated to be linked to changes in disturbed circadian- and sleep-wake-dependent phase relationships and concomitant increase of slow-wave-sleep pressure; additionally, SD-induced sleepiness may counteract the hyperarousal state in depression. This model has the advantage of providing a comprehensive theoretical framework and stringent protocols ("constant routine," "forced desynchrony") to dissect out specific disturbances. Many aspects tie in with current serotonergic receptor hypotheses of SD action. A treatment inducing euthymia in severely depressed patients within hours is an important therapeutic option that has come of age for clinical use.     

Text level reading comprehension in aphasia: What do we know about therapy and what do we need to know?

Background: Reading comprehension difficulties are a common feature of aphasia, affecting the understanding of single words, sentences, paragraphs and extended text. Whilst there have been studies investigating treatment for single word reading, there are a limited number of studies of treatment methods targeting the reading of paragraphs and connected text.

Aims: This paper will describe a series of single case studies, each investigating the effectiveness of a different therapy approach for paragraph level reading comprehension. The studies raise a number of issues regarding the assessment of reading, choice of therapy and measurement of outcome; these will be discussed in relation to the studies and the wider evidence base.

Methods & Procedures: Four people with aphasia were involved in the studies. Participants presented with reading difficulties alongside other language difficulties. Each study involved a single case study, multiple baseline with control task design. Detailed assessment of reading comprehension was completed pre-therapy, post-therapy and at follow-up, approximately 2–4 weeks post-therapy. Participants were also asked about their pre-morbid reading abilities and preferences, their reading difficulties and their views about therapy and its impact.

Outcomes & Results: All participants showed some improvement in the accuracy of reading comprehension but there was extensive variability in the significance of gains, when gains were seen and on which assessments. Post-therapy, three of the four participants read the assessment passages and answered the questions more quickly. All participants reported some positive change in their reading, either in reading ability, reading behaviour or feelings about reading, but again individual variation was evident in the extent and type of change perceived.

Conclusions: These studies raise a number of important issues regarding the assessment of reading, therapy choice and measuring the outcome of therapy. These issues are discussed in relation to current literature, with an aim of informing future research investigating the assessment of, and therapy for, reading comprehension difficulties in people with aphasia. Reading is fundamental to everyday activities and developing the evidence base is of crucial importance in supporting people with aphasia to maximise their reading ability.     

Predicting and preventing suicide: do we know enough to do either?

In population studies, many risk factors are associated with suicide completion. Yet we cannot accurately predict whether any individual patient will die by suicide. Completers are a distinct population from attempters and do not necessarily present for treatment by mental health professionals. Research on suicide prevention has yielded some promising findings but has not shown that interventions produce definitive results. The strongest evidence for successful prevention derives from reducing access to means. A population-based strategy may be more effective than a high-risk strategy focusing on patients with suicidal ideas or attempts. Much more research is needed before developing effective suicide prevention programs.     

What do we know about IDH1/2 mutations so far, and how do we use it?

Whole genome analyses have facilitated the discovery of clinically relevant genetic alterations in a variety of diseases, most notably cancer. A prominent example of this was the discovery of mutations in isocitrate dehydrogenases 1 and 2 (IDH1/2) in a sizeable proportion of gliomas and some other neoplasms. Herein the normal functions of these enzymes, how the mutations alter their catalytic properties, the effects of their d-2-hydroxyglutarate metabolite, technical considerations in diagnostic neuropathology, implications about prognosis and therapeutic considerations, and practical applications and controversies regarding IDH1/2 mutation testing are discussed.     

Recovery-based practice: do we know what we mean or mean what we know?

The concept of recovery is now widely promoted as the guiding principle for the provision of mental health services in Australia and overseas. While there is increasing pressure on service providers to ensure that services are recovery oriented, the way in which recovery-based practice is operationalized at the coalface presents a number of challenges. These are discussed in the context of five key questions that address (i) the appropriateness of recovery as a focus for service delivery, (ii) the distinction between recovery as a process and an outcome, (iii) the assessment of recovery initiatives, (iv) the alignment of recovery with current service delivery models, and (v) the risks associated with recovery-based practice. It is argued that these questions provide a framework for a debate that must extend beyond patients and providers of mental health services to the broader public, whose attitudes will ultimately determine the possibilities and limits of recovery-oriented practice.     

Epilepsy stigma: what do we know and where next?

Stigma is a major issue for people who develop epilepsy. Reducing stigma is a major focus of activity for the epilepsy patient support groups globally. In this paper, we introduce some key ideas and debates about the nature of and drivers for the stigma of epilepsy, including recent arguments about the need to frame analyses of the nature of epilepsy stigma within sociological debates about conflict and power. We then consider the role of the legislative process for redressing power imbalances that promote or maintain epilepsy stigma; and the value of tailored educational campaigns and programmes directed at stigma reduction. Finally, we consider the nature of ‘difference’ as experienced by people with epilepsy and how that difference translates into stigma; and provide evidence from a specific targeted intervention to combat epilepsy stigma that its reduction is an achievable goal.     

Brain temperature: what do we know?

This review article presents a summary of recent efforts to understand brain temperature and its regulation under different conditions. Brain temperature has a crucial influence on brain processes. Its regulation is the outcome of the balance of core and arterial blood temperatures, cerebral blood flow, brain metabolism, functional conditions, and external temperature. However, the relationship between these factors is not fully understood and several uncertainties remain. There are no satisfactory normative data on temperatures throughout the brain, but new technologies promise to fill this gap. Brain temperature changes with brain functional activation and under pathological conditions in ways that are not understood. A full understanding of brain temperature control is mandatory to optimize attempts at brain cooling during clinical conditions such as stroke and head injury.     

Empathy. We know what we mean, but what do we measure?

In recent years, quantitative researches on the empathic process in psychotherapy have resulted in definite recommendations for the technique of psychotherapy and the training of psychotherapists. What is not always observed, however, is that the methods employed for studying empathy have been based on brief segments of patient-therapist interaction in which judgments of empathy do not depend on hearing the patient's communications, and are in several ways discordant with what is meant by empathy according to clinical theory. Evidence suggests that it is the rater's impression of the "goodness of psychotherapy" rather than empathy that is being captured by these methods.     

Burnout and psychiatrists: what do we know and where to from here?

Medicine in most parts of the world is becoming a stressful profession. Psychiatrists represent a high-risk group among doctors for experiencing burnout, alcohol and drug use, posing suicide risk and other forms of work-related stress. There are reports that entrants in the profession of psychiatrists are decreasing globally. Conceptual issues related to burnout are explored and factors contributing to burnout in psychiatrists are reviewed. Methodologically sound studies are needed to help us understand positive aspects of psychiatry as a profession and the environment psychiatrists work in. Effective treatment programmes for burnout are also needed not only to reduce suffering but also to retain psychiatrists in the profession.     

Psychopharmacologic interventions in nursing homes: what do we know and where should we go?

Psychiatric symptoms are common among individuals who live in nursing homes, with prevalence rates ranging from 51 percent to 94 percent. Accordingly, psychotropic medications are widely prescribed in this setting and are the subject of considerable debate and regulation. Current regulations arose from public and governmental concerns that psychiatric medications were being prescribed inappropriately to frail patients. Concern has also been raised about the absence of evidence on which to base prescribing decisions. Nursing homes are slowly being recognized as complex health care settings that warrant considerable research attention. This article explores the origins of the regulation of the use of psychotropic drugs in nursing homes, reviews controlled trials of these drugs in nursing homes, examines the role of these agents in adverse drug events experienced by nursing home residents, and proposes policy and research areas that merit consideration.     

Hiring and retaining direct-care staff: after fifty years of research,what do we know?

Recruiting and retaining direct-care staff has long been a challenge for administrators of programs that serve persons with disabilities. A literature review revealed that beginning in 1950, researchers set out to develop a paper-and-pencil test that would identify good employees. Regardless of how they defined good, employers were unable to identify tests that selected promising job applicants. Efforts to develop research-based selection tools decreased in the early 1970s with the transition from state institutions to community programs. However, the growth of community programs did not mitigate the turnover problem, and the need remains for a reliable hiring tool. Whereas recent researchers have identified practices that can reduce turnover, these practices should be more widely implemented and their efficacy examined.     

Racial/ethnic disparities in the treatment of epilepsy: what do we know? What do we need to know?

We examine current understanding of the minority disadvantage in the clinical management of epilepsy. We performed an online literature search using several keywords (race, ethnicity, epilepsy, treatment, and quality of life) and identified additional literature through cross-referencing/manual search. The search produced 58 items published between 1977 and 2005. Of 49 original research studies, 38 were quantitative, 7 were qualitative, and 4 used mixed methods. Three or more articles were published in Epilepsia, Epilepsy &Behavior, Epilepsy Research, Neurology, and Seizure. Research concerning racial/ethnic differences in epilepsy treatment is scarce and limited by methodology, but suggests underutilization of state-of-the-art therapies by minorities. Racial/ethnic minorities also appear to have limited knowledge about epilepsy and its treatment, experience barriers to care, lack social support, and seek alternative therapies for epilepsy. We propose a framework to identify the array of disparities, points of intervention, and interventions.     

Targeting repetitive transcranial magnetic stimulation in depression: do we really know what we are stimulating and how best to do it?

BackgroundRepetitive transcranial magnetic stimulation (rTMS) is an established treatment for patients with depression who have not achieved optimal outcomes with one or more trials of antidepressant medication. It is an effective antidepressant treatment but there remains considerable scope for improving clinical outcomes. One method to potentially enhance the efficacy of rTMS is through the improvement of methods of stimulation localization.ObjectiveThe purpose of this paper is to review the literature pertaining to rTMS localization methods and approaches relevant to the treatment of major depressive disorder (MDD) and provide specific opinions on the state of the art in regards to targeting of rTMS treatment in depression.MethodsA targeted review of the literature on rTMS targeting in depression.ResultsThere is emerging evidence that optimal rTMS treatment outcomes are likely to be achieved with stimulation at a relatively anterior stimulation site in the left dorsolateral prefrontal cortex (DLPFC). However, some lines of research suggest that there may be two effective stimulation sites: one quite posterior, and one more anterior, in the DLPFC. The ‘Beam F3’ method provides reasonable localization to the anterior stimulation site and the posterior stimulation site corresponds to that typically used in studies using the ‘5 cm method’. Neuro-navigational methods are generally most likely to consistently ensure placement of the TMS coil such that it results in stimulation of a selected cortical site. fMRI – connectivity based approaches to targeting specific circuits in the DLPFC are intellectually attractive but it may not be possible to demonstrate differential effectiveness of these over the methods most commonly been used in clinical practice.ConclusionsThere is an emerging literature helping to improve our understanding of the optimal methods for targeting rTMS treatment for depression. However, we lack substantive prospective clinical trials demonstrating improved clinical outcomes with these techniques.     

What do we know about the relationship between source monitoring deficits and executive dysfunction?

In clinical neuropsychology, source monitoring deficits have been classically attributed to executive dysfunction. Nevertheless, in this review we identified only 16 papers that provided statistical data about the relationships between source monitoring and executive processes. Surprisingly, they reported either a total, partial or non-existent relationship between source monitoring and executive tasks. In order to understand and explain these contradictions, we classified the source and executive tasks of the 16 papers according to two well-accepted definitions. Source tasks were classified using the Source Monitoring Framework (Johnson, Hashtroudi, & Lindsay, 1993 ) which specifies reality and external and internal source monitoring. Executive tasks were classified according to the model of Miyake Friedman, Emerson, Witzki, and Howerter (2000) which specifies complex, shifting, updating and inhibition tasks. We found that evaluation of reality and internal source monitoring was limited. Regarding executive functions, there was no assessment of updating and only a limited assessment of shifting and inhibition. Therefore, the relationship between source monitoring and executive functions remains an open question. Our findings point to the need for the simultaneous assessment of source monitoring and executive functions as defined by multidimensional theoretical frameworks. Such investigations would help in understanding the relationship between specific source monitoring deficits and specific executive decline in clinical populations.