Welcome to the Forty-Sixth Edition of Encephalon, a neuroscience blog carnival.
The best neuroscience posts of recent on The Neurocritic
Wednesday, May 28, 2008
Encephalon 46th edtion on The Neurocritic
The best neuroscience posts of recent on The Neurocritic
Tuesday, May 27, 2008
Grand Round 4.36 on Parallel Universes
This is my 5th time to host (Thanks, Nick!) and I have not stopped enjoying the privilege of hosting this wonderful weekly anthology of the best posts of the medical blogosphere. Since FIVE is the lucky number for me today, I am opening this round with five of the best posts submitted to me this week...
A lot of excellents posts from the medblog sphere, go read them on Parallel Universes
Monday, May 26, 2008
Grand Round: Gene Genie #32 - Googling the Genie
Welcome to the 32nd edition of Gene Genie, a blog carnival devoted to genes and genetic conditions. This edition includes some excellent articles on genes and gene-related diseases, genetics, genomics and personalized genetics.
Dr Shock is in this excellent grand round with genes and gene related diseases. Go read these excellent articles about the newest research on genes: the 32nd edition of Gene Genie
Saturday, May 24, 2008
Blog Addicted or Internet Addicted
The next three weeks Dr Shock is on vacation. This blog has been updated daily for more then a year. Since blogging is fun I will probably keep on blogging during these three weeks but maybe not daily and the long posts your used to.
No cold turkey to prevent withdrawal symptoms from blog addiction or is it Internet addiction? Won't need shocktherapy for this I hope. But blogging is good for your health, at Living the Scientific Life
By the way there another stupid thing people believe you can get addicted to. Here is a good one: internet dating. Thanks Pure Pedantry
After these three weeks I will probably start with a new design, maybe I will need your help with that, looking forward to all this.
Cognitive Safety of Deep Brain Stimulation for Treatment Resistant Depression
Apart from a transient mild decline in manual motor speed, there seems to be no
adverse cognitive effects associated with chronic Deep Brain Stimulation (DBS) in Cg25 for Treatment Resistant Depression (TRD) in this sample of 6 patients with a follow-up of 12 months.
Another important conclusion from this research:
Several areas of cognition that were below average or impaired at baseline improved over follow-up, and these changes were not correlated with improvements in mood.
Broadman Area 25 as target for deep brain stimulation in treatment resistant depression. This area in the brain is from the most important publication about DBS and depression in Neuron march 2005 by Helen Mayberg. This is the location used in the largest trial with DBS in TRD. Other locations for DBS in TRD appear as well but these publications concern individual cases.
Functional neuroimaging as well as antidepressant treatment effects suggest that this area plays an important role in modulating negative mood states. Clinical response was demonstrated in 4 of 6 patients using standardized psychiatric end points. These results suggest that modulation of pathological activity in specific limbic-cortical circuits by electrical stimulation of Cg25 can effectively reverse symptoms in previously TRD patients.
Comparison to ECT
Moreover, in contrast to the memory deficits consistently reported with
ECT, no consistent declines in memory for either verbal or visual material were noted after onset or maintenance of DBS over baseline.
Limitations
- small sample size (n=6)
- the lack of a matched control group
- the lack of control (on-off) conditions for stimulation
- impact of repeat testing or regression toward the mean may have nonetheless affected the results
- patients were not free of psychopharmacological drugs
Other indications for DBS:
McNeely, H.E., Mayberg, H.S., Lozano, A.M., Kennedy, S.H. (2008). Neuropsychological Impact of Cg25 Deep Brain Stimulation for Treatment-Resistant Depression. The Journal of Nervous and Mental Disease, 196(5), 405-410. DOI: 10.1097/NMD.0b013e3181710927
Friday, May 23, 2008
3 Health Portals
Other blog such as clinical cases and Medgadget also discovered the news around Google Health. For some screen shots see Dr Shock. Eye on FDA also reviews Google Health:
It is a pretty neat concept and, as a big fan of Google myself, I can say that it maintains Google standards for easy maneuverability and is extremely friendly for the user. If you use a Google Reader as an aggregator - this is far easier to negotiate. You put in a few details about yourself, including your medications and already can gain access to a good deal of interesting information.
The other contester looking for your medical history is Microsoft with HealthVault. A screen shot is on the top of this post. You will need a LiveID or create one. Tried to create a LiveID, very difficult, it kept complaining about the strength of my password. Even medium strength was not enough, doesn't sound hopeful if they even don't trust their own system.
The website of the Canadian Medical Association has it's own system for patient information and medical history: http://www.mydoctor.ca Health Portal
The new portal, created by Practice Solutions, a CMA company, allows physicians to register their patients with any or all of the online tools the portal offers - asthma tracker, blood pressure tool and weight tracker and a personal health record. Designed by physicians, the portal also provides secure messaging, ensuring a private channel of communication between patient and doctor.
"This service really shows the role of technological innovation in raising the standards of health care delivery in Canada," said Dr. Brian Day, President of the CMA. "The mydoctor.ca Health Portal provides a new way for physicians to give each patient the care and attention they deserve while also empowering patients to become active participants in their care."
Here is a screen shot of the patient's dashboard.
You can read the Press release about mydoctor.ca
Thursday, May 22, 2008
Peer Review Is Sacred
Peer review means reviewing the research of other scientists in your field for publication in a scientific journal. This procedure is confidential. Reviewers should abstain from peer review if there is a conflict of interest not only financial but also scientifically.
Pfizer subpoenaed the New England Journal demanding that the Journal produce peer-review and other editorial documents on all manuscripts concerning Pfizer's cyclooxygenase-2 (COX-2) inhibitors, valdecoxib (Bextra) and celecoxib (Celebrex) specific articles that they had published and any others that we had rejected for publication. Pfizer wanted the peer-review documents, including the critiques prepared by reviewers for the authors, to help defend itself in product-liability litigation, the company was not looking for specific information. Pfizer was hoping to use the Journal's expert reviewers and their critical commentary in an attempt to challenge scientific aspects of the articles, adding what Pfizer's attorneys called the "significant imprimatur" of the Journal to their case.
Fortunately
the judge decided that while the materials Pfizer sought were relevant, their probative value was limited. As Sorokin concluded, even though the information sought was relevant, "the NEJM's interest in maintaining the confidentiality of the peer-review process is a very significant one, especially in light of its non-party status, and tips the scales in favor of the NEJM."
Yoiu can read the whole editorial: Peer Review in the Balance
Screening Adolescents for Depression on the Internet
Screening for depression through the Internet is feasible and is acceptable to large groups of adolescents. Furthermore, the Major Depression Inventory (MDI) and the Center for Epidemiological Studies-Depression scale for Children (pdf, small) (CES-D) are reliable and valid instruments that can be used for this screening.
By the age of 18 about one in every four adolescents has had at least one
depressive episode, and most adults with recurrent depression have their initial depressive episodes as teenagers
Teen depression or depression during adolescence can be hard to discover. There is even a website about depression for children and parents: KidsHealth. It is a doctor-approved website with health information about children from before birth through adolescence. KidsHealth provides families with accurate, up-to-date, and jargon-free health information they can use.
Treatments for depression in adolescents are available. Usually treatment is started with cognitive therapy. The combination with antidepressants is also very effective in treating depressed adolescents.
Despite the availability of effective treatments, however, undertreatment is considerable in depressed adolescents because:
- adolescents tend to consider help-seeking as a sign of weakness
- they do not consider their problems to be mental health problems that can be treated
- they prefer to solve their problems on their own
- both parents and health professionals consider mental health problems a normal part of adolescence
The Internet may be an acceptable medium for adolescents to receive help.
In this research two screening instruments for depression in adolescents the Center forEpidemiological Studies-depression scale(pdf, small)(CES-D); and the major depression inventory, MDI) were validated for the use through the Internet.
What was done in this research?
A total of 1,392 adolescents, recruited through high schools and the
Internet, filled in the online questionnaires. Of these, 243 (17%) were interviewed with the MINI diagnostic interview to assess the presence of a mood disorder.
So not only were these screening instruments used they were also validated against the the International Neuropsychiatric Interview (MINI). Not the best diagnostic instrument but a good one.
From the two screening instruments the MDI has the advantage that it is considerably shorter than the CES-D (12 compared to 20 items), and requires less time input from the adolescents.
Several recent studies have shown that Internet-based interventions are as effective in the treatment of depression as more traditional types of psychological treatment, although most of these studies have been conducted with adults. But Cognitive Therapy through Internet might be an acceptable treatment and medium for depressed adolescents.
Cuijpers, P., Boluijt, P., Straten, A. (2008). Screening of depression in adolescents through the Internet. European Child & Adolescent Psychiatry, 17(1), 32-38. DOI: 10.1007/s00787-007-0631-2
Wednesday, May 21, 2008
New Grand Round
The New Grand Round of this week is up on Musing of a Dinosaur.
Grand Rounds has become the contemporary weekly portrait of medicine through the eyes of the medical bloggers.
Life Hacks for Doctors
Dr Shock is a fan of Life hacks. He even reviewed some books about it on this blog: Getting Things Done, and Upgrade Your Life.
But now he discovered a slide show with Life Hacks for Doctors. There is even a blog dedicated to efficiency for doctors: The Efficient MD and a WIKI.
The Efficient MD Wiki is designed to help healthcare professionals and medical students discover clinical pearls, useful resources, life hacks, and strategies to improve the practice of medicine.
Thanks clinical cases and images, who is also a collaborator on this new project, The Efficient MD Wiki.
Facts about Chocolate and Health
- Cocoa is rich in polyphenols, similar to those found in green tea, and as polyphenols have been shown to have beneficial effects on cardiovascular disease such as hypertension, stroke, myocardial infarction but also diabetes
- For cocoa, the terms that are used to describe the particular compounds of interest are flavanols. Flavanols are a subclass of flavonoids which are, in turn, a subclass of polyphenols
- Cocoa is the non-fat component of cocoa liquor (finely ground cocoa beans) which is used in chocolate making or as cocoa powder (commonly 12 % fat) for cooking and drinks
- Chocolate refers to the combination of cocoa, cocoa butter, sugar, etc. into a solid food product
- In Europe, 58 % of people ate milk chocolate, closely followed by dark chocolate (43 %)
- Cocoa taken as a beverage is popular in Spain
- There were two human trials with interventions using cocoa published in 2001, three in 2002, five in 2003, three in 2004, six in 2005 and five in 2006 (one so far in 2007). More often than not, the studies yield at least one positive and significant result
- The research is predominantly focused on effects on the vascular system, however, there are other areas of research on man in vivo which are not so extensively investigated, such as those concerned with cognition, cancer and diabetes
- The mechanism of action of cocoa polyphenols including clinical, pre-clinical and in vitro studies consistently show changes in biomarkers related to oxidative status and/or vascular function
- High cocoa content dark chocolate tends to be richest in polyphenols, although each chocolate is different in polyphenol content
- For future research:
- Where possible, conduct randomised, controlled, cross-over, multi-dose trials
- Use well-defined cocoa or chocolate
- Use an appropriate control of no-polyphenol chocolate
- Recruit volunteers with at least one non-optimal biomarker or disease risk factor
Cooper, K.A., Donovan, J.L., Waterhouse, A.L., Williamson, G. (2008). Cocoa and health: a decade of research. British Journal of Nutrition, 99(01) DOI: 10.1017/S0007114507795296
Tuesday, May 20, 2008
Psychiatry in Bagdad
But Dr. Hussain, who entered his profession at a time when Iraqi doctors were among the most sophisticated and highly trained in the Middle East, is caught in a time warp in a war-torn land where knowledge and sophistication have been largely overwhelmed by third-world decay, and ancient equipment has plunged some treatments into a “One Flew Over the Cuckoo’s Nest” barbarism, despite the best intentions.
Article in The New York Times, shocking news
Google Health, One More Step
In Google Health you can now add your health information. You can add your diseases and medication use. The systems alarms when dangerous interactions appear with your different medications. You can also add allergies.
You can even add medical records from sources of which a few of are shown in the next figure
When you link a website to your profile, you may authorize that website to read your Google Health profile or to automatically send and update information in your profile (such as medical records or prescription histories). You decide which permissions to grant when you sign up with each website.
All you need is a google account.
Thanks lifehacker.com
If you're willing to hand over your medical profile to the big G in the name of convenient info, Google Health is for you. The more privacy-minded, of course, may refrain.
Monday, May 19, 2008
Supportive Psychotherapy mostly Novice Pilots Flying In The Dark Without Maps
Supportive therapy in psychiatry is mostly done by unexperienced psychiatric residents during their training. Most residents as well as psychiatrists think that supportive therapy is just providing a sense of safety, support self esteem and hope, alternated by advice how patients should live their life, structure their day, get to work and behave. Psychiatrist the least qualified usually apply for the supervision of residents doing these therapies based on these premises.
To my opinion these kind of therapies are the hardest to do, need the most experienced and psychotherapeutic best qualified psychiatrists. Yes psychiatrists because this kind of therapy is mostly done with the most vulnerable patients with sever psychopathology and usually with several diagnoses. Sure residents can be trained in supportive therapy and they should be.
What makes supportive psychotherapy besides the patients in need for it so difficult?
- It is not just common sense, interpersonal skills, and a capacity for empathy.To my opinion it is a psychotherapy as dimension of dynamic psychotherapy, to a greater or lesser extent depending on the particular context, problems, and needs of the person. Interpretive approaches and transference work must also be used with the so-called less suitable patients who have a history of immature object relations in this kind of treatment. But it has to be used wisely.
- Supportive psychotherapy relies heavily on psychoanalysis in describing characteristic techniques, such as “improving ego functions,” “minimizing the focus on transferential material,” and “confronting maladaptive defenses,” thus assuming some familiarity with ego-psychological psychodynamic theory. For beginning psychotherapists it can hardly be expected to understand what it means to “manage” or “manipulate” the transference in supportive therapy and how this differs from “interpreting” the transference in a more exploratory treatment, let alone which patients under what circumstances require such “management” and why.
- Without a good working hypotheses about the unconscious motives, feelings,
and conflicts underlying a person’s distress, it is also difficult to see how they would have any basis for predicting what would be supportive or nonsupportive for the individual patient at any given moment in the treatment. - You also need to understand the differences between thinking psychoanalytically in providing support and acting like a psychoanalyst.One of the most important rules is: “Do not say everything you know, only what will be helpful.”
- The supportive therapist helps the patient see things more clearly by supporting
reality testing, tactfully challenging unrealistic ideas, and demonstrating more effective, less costly ways of defending while supporting adaptive defenses.you have to understand these different aspects in your patient before you can even work on it. - The main priority in supportive psychotherapy is to build a “holding environment”
and to foster the therapeutic alliance. This is hard to dose, most unexperienced therapist remain to silent, distant. - It is hard to know about how responsive and self-revealing you should be, about what, and why. The best way to learn this is in supervision. Supervisors should feel free to share their own learning process, including any gaffes, confusion, and embarrassing moments they may have experienced along the way.
- You should realize that small improvements can lead to bigger changes and that setting overly ambitious goals will only increase the likelihood of failure. Doing “just enough” is good enough—just enough to reduce anxiety,build self-esteem, instill hope, support deficient psychological functions, and improve overall functioning.
The biggest problem with this effective and satisfying kind of treatment is the lack of a clear definition, consensus about training and guidelines for supportive therapy.
This post is based on Teaching Supportive Psychotherapy to Psychiatric Residents by Carolyn J. Douglas, M.D. and published in the American Journal of Psychiatry 165:4, April 2008, but holds the views of the author of this post: Dr Shock
By the way it is an excellent account of supportive therapy
Sunday, May 18, 2008
Iceland has the Happiest People in the World
This blog is mostly about depression and it's treatment. Today some happy news.
Iceland, the block of sub-Arctic lava to which these statistics apply, tops the latest table of the United Nations Development Programme's (UNDP) Human Development Index rankings, meaning that as a society and as an economy - in terms of wealth, health and education - they are champions of the world.
And why is that?
- It is the country with the sixth highest GDP per capita in the world
- Where people buy the most books
- Where life expectancy for men is the highest in the world, and not far behind for women
- It's the only country in NATO with no armed forces (they were banned 700 years ago)
- The highest ratio of mobile telephones to population
- The fastest-expanding banking system in the world
- Rocketing export business
- Crystal-pure air
- Hot water delivered to all Icelandic households straight from the earth's volcanic bowels
- and so on and so forth...
Want to know how this came about, read the excellent article John Carlin on The Guardian: No wonder Iceland has the happiest people on earth.
It has something to do with them Vikings.
Saturday, May 17, 2008
I knew it, Tetris can make you Smarter
Bass-Krueger wanted to test how large this effect was. He had some of his several dozen subjects play Tetris for 15 minutes. Then he gave everyone a spatial reasoning test similar to those used in IQ assessments. The results were staggering: Tetris players scored more than 55% higher than the control group. “Even in 15 minutes it can still have an effect,” Bass-Krueger told us here in Atlanta at the Intel International Science & Engineering Fair, where he presented his results.
In Scientific American
More healthy games
Friday, May 16, 2008
US Citizens have a Distorted World View
Watch this video and you will know why.
Alisa Miller, head of Public Radio International, talks about why -- though we want to know more about the world than ever -- the US media is actually showing less. Eye-opening stats and graphs.
How can Genes and Stress cause Depression?
The answer is: in the stress system. Stress reactivity might be an important link between a genetic variant of the serotonin transporter gene, stressful life events in early years and depression.
There is evidence of interaction between a functional genetic variant of the serotonin transporter gene and life events. Depression is not based on a simple gene or a cluster of genes. But on a gene and environment interaction. So the risk of getting a depression is higher when a certain genetic variant of the serotonin transporter gene is present in the presence of life stress, especially in early life. But how does this genetic predisposition and life stress lead to depression?
Cortisol, a reliable indicator of hypothalamic pituitary-adrenocortical (HPA) axis functioning and stress reactivity has a hereditary component and is also elevated in 40%–60% of adults diagnosed with depression.
How was this research done?
Girls at high (n=25) and low (n=42) risk for depression by virtue of the presence or absence of a family history of this disorder were genotyped and exposed to a standardized laboratory stress task. Forty-two girls had biological mothers with no current or past Axis I disorder (low-risk daughters), and 25 girls had biological mothers with a history of recurrent episodes of depression during their daughter’s lifetime (high-risk daughters). Cortisol levels were assessed before the stressor, after the stressor,and during an extended recovery period.
The two groups of daughters did not differ significantly in their genotype distribution.
And the results?
Daughters who are homozygous for the s allele showed a marked increase in cortisol production during and following exposure to the stressor. In contrast, daughters with at least one copy of the l allele exhibited a slight decrease in cortisol production over the course of the stress session.See the figure.
These results explain in part why stress in some people can lead to depression and not in others. This is not a black and white outcome. Some people without the s allele can also get a depression but usually with a lot more stress compared to those with a s allele. Probably these findings can't explain everything about the origins of depression but these findings sound plausible. They probably only apply to certain depressions such as melancholic depression and they probably differ based on ethnicity but nevertheless these results are encouraging to my opinion.
Research into how the serotonin system plays a role in regulating HPA axis activity might shed some light on further mechanisms.
Biological stress reactivity is a plausible mechanism underlying the association between genotype and exposure to life stress in predicting the onset of depression.
In the future it might be possible to discover high risk individuals and develop treatment or prevention programs.
Serotonin and the transporter gene
Serotonin is an important neurotransmitter believed to play an important role in depression. The transport of serotonin during reuptake in the neuron from the synaps is done by a protein. The production of this protein is dependent on certain genes. The variant of this gene affects how much serotonin transporter protein is produced. Individuals with the short allelic form of this variant showed an increased risk of depression compared to those carrying the long allele but only when exposed to adverse life events or maltreatment. There have been some nonreplications, but these have been outnumbered by the number of replicated findings. The original science abstract of the article on influence of life stress on depression is freely available
GOTLIB, I., JOORMANN, J., MINOR, K., HALLMAYER, J. (2007). HPA Axis Reactivity: A Mechanism Underlying the Associations Among 5-HTTLPR, Stress, and Depression. Biological Psychiatry DOI: 10.1016/j.biopsych.2007.10.008
Thursday, May 15, 2008
Are we in need of a cases journal?
This is a call for cases to be submitted to this new journal. Not only the extraordinary exciting cases but all cases. The intention is to form a database with thousands of cases and a search function so that physicians as well as patients can look for e.g. male 52 years with COPD and non smoking. The focus is on outcome of these cases, that is what they want to know from the authors
Are we in need of this new journal? Don't think so.
Let me know in the comments
Wednesday, May 14, 2008
Speciality Choice of Medical Students, Impact of Clerkship
I wanted to be a psychiatrist before I went to Med School. Fascinated by the work of Jung and especially Freud, psychiatry seemed the ultimate goal for Med School. Encountered these pioneers while reading literature and a new goal was formulated. Before that my hart was set on social geography, thank god I changed my mind.Other factors such as the encounter with people out of the ordinary during my earlier years most certainly did help my career choice but I found out after finishing Med School during residency in psychiatry.
During Med School I only once doubted my choice. It was during my clerkship of internal medicine. The head of the department, it was hematology, seemed to appreciate my interest in patients and internal medicine. He asked me to apply for a residency in Internal Medicine. Shortly thereafter he was diagnosed with oat cell tumor, lung cancer and died within 6 months and that was the end of my uncertainty about my specialty after med school.
Factors that are associated with choice of specialty based on earlier research are:
- Work content and willingness to work with chronically ill patients as important determinants of choosing a career in general practice.
- Students who sought surgical training attached greater importance to prestige and career opportunities.
- Increased awareness of a specialty and clinical experiences during clerkships are associated with shifts in preferences and eventual specialty choice.
- General practice clerkships encourage students to pursue further training in this specialty
- Women are more likely to prefer part-time work and opportunities to combine work and personal life and they choose a career in community based areas and social medicine
- Men are typically more attracted by technical challenges, prestige and learning potential and they prefer hospital-based specialties
What did this research do?
They carried out a longitudinal cohort study to collect data on career preferences and attitudes towards future careers among 3 cohorts of students before and after clerkships in surgery (n = 200), internal medicine (n = 277) and general practice (n = 184).
And what did they find?
- Students were encouraged by the clerkship to consider a future career in the specialty of the rotation. Many students saw their ideas regarding a specialty, whether positive or negative, reinforced during the clerkship and, as a result, did not alter their preferences.
- Relatively more male than female students preferred a career in surgery, and more female than male students preferred a career in general practice.
- Men opted more for surgery and women for general practice.
- Experiences in primary care settings promote an interest in general practice and show it to have advantages that were not considered or known of beforehand.
- Gender differences regarding career choice appear to be not only based on typical male and female choices but to be a combination of attitudinal factors, such as type of preferred patients and work (technology oriented work and emergency situations versus chronic patients and palliative care) and lifestyle preferences (part-time work or career and income orientation).
Overall what can be learned from this research is that students choose a specialty
on the basis of the work content experienced during a clerkship. The results also show that it is the content of the work that matters. So clinical teachers, the clerkship is the time to promote your specialty.
My clerkship for psychiatry was not representative of psychiatry as I know it today. It was a clerkship at a medium stay care facility in a state hospital. My first encounter with real work in psychiatry was emergency psychiatry and I loved it and stayed for 2 years. Residency in a University Hospital did the rest. Still love my job.
Maiorova, T., Stevens, F., Scherpbier, A., van der Zee, J. (2008). The impact of clerkships on students’ specialty preferences: what do undergraduates learn for their profession?. Medical Education, 42(6), 554-562. DOI: 10.1111/j.1365-2923.2008.03008.x
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