The neurobiology of childhood trauma, from early physical pain onwards: as relevant as ever in today's fractured world.

Background: The situation in the world today, encompassing multiple armed conflicts, notably in Ukraine, the Coronavirus pandemic and the effects of climate change, increases the likelihood of childhood exposure to physical injury and pain. Other effects of these worldwide hardships include poverty, malnutrition and starvation, also bringing with them other forms of trauma, including emotional harm, neglect and deliberate maltreatment. Objective: To review the neurobiology of the systems in the developing brain that are most affected by physical and emotional trauma and neglect. Method: The review begins with those that mature first, such as the somatosensory system, progressing to structures that have a more protracted development, including those involved in cognition and emotional regulation. Explored next are developing stress response systems, especially the hypothalamic-pituitary-adrenal axis and its central regulator, corticotropin-releasing hormone. Also examined are reward and anti-reward systems and genetic versus environmental influences. The behavioural consequences of interpersonal childhood trauma, focusing on self-harm and suicide, are also surveyed briefly. Finally, pointers to effective treatment are proffered. Results: The low-threshold nature of circuitry in the developing brain and lack of inhibitory connections therein result in heightened excitability, making the consequences of both physical and emotional trauma more intense. Sensitive and critical periods in the development of structures such as the amygdala render the nervous system more vulnerable to insults occurring at those points, increasing the likelihood of psychiatric disorders, culminating in self-harm and even suicide. Conclusion: In view of the greater excitability of the developing nervous system, and its vulnerability to physical and psychological injuries, the review ends with an exhortation to consider the long-term consequences of childhood trauma, often underestimated or missed altogether when faced with adults suffering mental health problems.

Antecedentes: La situación en el mundo actual, que abarca múltiples conflictos armados, mayormente en Ucrania, la pandemia del Coronavirus y los efectos del cambio climático, aumenta la probabilidad de exposición infantil a lesiones físicas y dolor. Otros efectos de estas dificultades mundiales incluyen pobreza, desnutrición y hambruna, también traen consigo otras formas de trauma, incluyendo daño emocional, negligencia y maltrato deliberado.Objetivo: Revisar la neurobiología de los sistemas en el cerebro en desarrollo que se ven más afectados por el trauma físico y emocional y la negligencia.Método: La revisión comienza con aquellos que maduran primero, como el sistema somatosensorial, progresando hacia estructuras que tienen un desarrollo más prolongado, incluidas las involucradas en la cognición y regulación emocional. A continuación se exploraron los sistemas de respuesta al estrés en desarrollo, especialmente el eje hipotálamo-hipófisis-adrenal y su regulador central, la hormona liberadora de corticotrofina. También se examinaron los sistemas de recompensa y anti-recompensa e influencias genéticas versus ambientales. Tambien se investigaron brevemente, las consecuencias conductuales del trauma infantil interpersonal, centrándose en las autolesiones y suicidio. Finalmente, se ofrecieron indicaciones para un tratamiento eficaz.Resultados: La naturaleza de bajo umbral de los circuitos en el cerebro en desarrollo y la falta de conexiones inhibitorias en ellos dan como resultado una mayor excitabilidad, lo que hace que las consecuencias del trauma físico y emocional sean más intensas. Los periodos críticos y sensibles en el desarrollo de estructuras como la amígdala hacen que el sistema nervioso sea más vulnerable a las agresiones que ocurren en esos puntos, lo que aumenta la probabilidad de trastornos psiquiátricos, culminando en autolesiones e incluso suicidio.Conclusión: En vista de la mayor excitabilidad del sistema nervioso en desarrollo y su vulnerabilidad a las lesiones físicas y psicológicas, la revisión termina con una exhortación a considerar las consecuencias a largo plazo del trauma infantil, con frecuencia subestimado o ignorado totalmente cuando nos enfrentamos con adultos que sufren de problemas de salud mental.

Experience with telemedicine in a multi-disciplinary ALS clinic.

OBJECTIVE: Telemedicine using video televisits is emerging as a means to provide care directly to patients. Here we report our experience using video televisits to provide follow-up care as a part of the Massachusetts General Hospital (MGH) Telemedicine for People with ALS (TelePALS) initiative. METHODS: This was a retrospective chart review of all video televisit encounters conducted by the MGH ALS clinic between September 2014 and January 2016. RESULTS: A total of 97 distinct ALS patients were seen using video televisits. Twenty-four percent of these patients had more than one video televisit. The median distance of the patients' primary residence to MGH was 211 miles. The average video televisit lasted 32 min (±12). About half the patients (54%) were ambulatory at the time of their video televisit. The most commonly addressed issues were medication management (89%), discussion of goals of care (74%), research (55%) and equipment use (50%). Acute care issues were rarely discussed. CONCLUSION: Video televisits are feasible and can be a useful tool to supplement traditional clinic-based multidisciplinary ALS care.