Complementary medicine for treatment of agitation and delirium in older persons: a systematic review and narrative synthesis.

BACKGROUND: Agitation and delirium frequently occur in cognitively impaired older people. We conducted a systematic review with narrative synthesis of the literature aiming to assess effectiveness of complementary and alternative medicine (CAM) modalities to address these conditions. METHODS: Following preliminary search, we included 40 original researches on CAM treatment of delirium and agitation in older persons. Then, the quality of these studies was assessed using the Downs and Black Checklist and Quality Assessment Tool for Studies with Diverse Designs, and the effect sizes were calculated. We subsequently conducted a narrative synthesis of the main findings, including theory development, preliminary synthesis, exploration of relationships within and between studies, and assessment of synthesis robustness. RESULTS: Forty articles that met the inclusion criteria were analyzed. Sixteen of these were randomized controlled trials. One article specifically addressed CAM treatment of delirium in patients without dementia, and the remaining 39 articles described treatments of agitated older persons with dementia. Thirty-five of the 40 included studies suggested that the investigated CAM therapies may ameliorate the severity of agitation and delirium. The physiological surrogates of agitation assessed in these studies included cortisol level, chromogranin A level, and heart rate variability. Very few of the studies systematically assessed safety issues, although no major adverse effects were reported. CONCLUSION: Overall, the systematic review of the literature suggests that several CAM modalities are potentially beneficial in the treatment of agitation and delirium among older persons. We suggest that promising CAM modalities should be further explored through large-scale randomized controlled trials in different clinical settings. Copyright © 2017 John Wiley & Sons, Ltd.

[THE CLINICAL AND DEMOGRAPHIC CHARACTERISTICS OF PATIENTS WHO FREQUENT THE PSYCHIATRIC EMERGENCY ROOM IN A GENERAL HOSPITAL].

INTRODUCTION: The recent policy implemented in Israel of reducing psychiatric admissions and the concomitant shifting of treatment to outpatient clinics, together with briefer stays in hospital and a growing number of repeat emergency room (ER) visits have created a "revolving door" phenomenon, whereby a small number of frequent attenders are responsible for a disproportionate fraction of ER visits. OBJECTIVES: To characterize psychiatric ER frequent attenders and understand their special needs by analyzing the "revolving door" phenomenon and defining the at-risk group. METHODS: Psychiatric attenders at the Ha'Emek Medical Center in Afula during a single year were divided retrospectively into three groups according to the number of their visits to the ER. One group had a single ER visit, an intermediate group had two to three ER visits, and a third group had four or more ER visits (frequent attenders). The groups were weighted by the respective number of attenders and analyzed using the optimal allocation technique. RESULTS AND CONCLUSIONS: The findings showed that people prone to frequently repeat visits to a psychiatric emergency room are familiar with the psychiatric system, unemployed, with an unstable income (or recipients of an allowance from the National Insurance), single or divorced, of Sephardic origin, have been hospitalized in the past, and are urban, native-born with social and family problems. From a clinical perspective the findings also showed thatthis subgroup comes to the ER without a referral, suffers from depression and psychotic states, personality disorders or mental retardation, has past suicide attempts, and the patients are under medication treatment. DISCUSSION AND SUMMARY: Frequent attenders make up a particularly difficult group of patients with major psychiatric disorders. The ER is not a fit setting for the treatment of such patients. The construction of a proper therapist-patient relationship is cardinal to attaining a meaningful remission. Prompt recognition of frequent attenders and their respective visiting pattern is required, allowing for a structured therapeutic approach which will include patient and family guidance and an algorithmic handling of emergency situations.

A randomized add-on trial of high-dose D-cycloserine for treatment-resistant depression.

Antagonism of N-methyl-D-aspartate glutamatergic receptors (NMDAR) may represent an effective antidepressant mechanism. D-cycloserine (DCS) is a partial agonist at the NMDAR-associated glycine modulatory site that at high doses acts as a functional NMDAR antagonist. Twenty-six treatment-resistant major depressive disorder patients participated in a double blind, placebo-controlled, 6-wk parallel group trial with a gradually titrated high dose (1000 mg/d) of DCS added to their antidepressant medication. DCS treatment was well tolerated, had no psychotomimetic effects and led to improvement in depression symptoms as measured by Hamilton Depression Rating Scale (HAMD; p = 0.005) and Beck Depression Inventory (p = 0.046). Of the 13 subjects treated with DCS, 54% had a ≥ 50% HAMD score reduction vs. 15% of the 13 patients randomized to placebo (p = 0.039). A significant (p = 0.043) treatment× pre-treatment glycine serum levels interaction was registered. These findings indicate that NMDAR glycine site antagonism may be a cost-effective target for development of mechanistically novel antidepressants. Larger-sized DCS trials are warranted.

D-serine adjuvant treatment alleviates behavioural and motor symptoms in Parkinson's disease.

Parkinson's disease (PD) manifestations include motor symptoms and behavioural deficits that resemble schizophrenia negative symptoms. The N-methyl-D-aspartate subtype of glutamate receptor (NMDAR) represents a novel pharmacological target in PD. D-serine (DSR) allosterically modulates in-vivo NMDAR-mediated neurotransmission and has been shown to improve negative and antipsychotic drug-induced parkinsonian symptoms in schizophrenia patients. This pilot study assessed DSR effects in ten PD patients who completed a 6-wk double-blind, placebo-controlled, crossover adjuvant treatment trial with 30 mg/kg.d DSR. Primary outcome analyses consisted of separate repeated-measures multivariate analyses of variance for Unified Parkinson's Disease Rating Scale (UPDRS), Simpson-Angus Scale for Extrapyramidal Symptoms (SAS), Abnormal Involuntary Movement Scale (AIMS), and Positive and Negative Syndrome Scale (PANSS) scores. DSR treatment was well tolerated and resulted in increased DSR serum levels (p=0.001) and significantly reduced UPDRS (p=0.02), SAS (p=0.009) and PANSS (0.05) total scores. These preliminary findings suggest that DSR treatment may be beneficial in PD. Larger-sized studies with optimized DSR dosages are warranted.

Differential Impact of Work Overload on Physicians' Attention: A Comparison Between Residential Fields.

OBJECTIVES: Medical errors cause tens of thousands of deaths annually and have a major impact on quality of care and management; however, it receives scant research and public awareness. This study aimed to examine the relation between workload-induced lack of sleep and attention failure, as indications for medical errors risk, among young residents. METHODS: We performed an evaluation of young physicians by the Test of Variables of Attention, before and after a 24-hour shift. RESULTS: Workload was manifested by 13% overall attention impairment at baseline, which increased to 34% with deficiencies below the normal range after the shift. Attention measures differed between physicians of each residential field at baseline, but to greater extent after the shift. CONCLUSIONS: Traditional working schedule is strongly associated with attention failure. Based on the literature linking attention failures to medical errors, we suggest a regulatory change regarding residents' shift duration to decrease preventable errors.

Dog training alleviates PTSD symptomatology by emotional and attentional regulation.

Background: Post-Traumatic Stress Disorder (PTSD) symptoms include re-experiencing, avoidance, hyperarousal, and cognitive deficits, reflecting both emotional and cognitive dysregulation. In recent years, non-pharmacological approaches and specifically animal-assisted therapy have been shown to be beneficial for a variety of disorders such as Attention-Deficit/Hyperactivity Disorder, Autism Spectrum Disorder, and PTSD. However, little is mentioned in the literature about the reciprocal effects of the animal-human interaction. Objective: To evaluate the effects of a one-year dog training programme on PTSD symptomatology in youngsters with PTSD and on dogs' behaviour. Methods: Fifty-three adolescents, previously exposed to interpersonal trauma, were clinically diagnosed with PTSD and assigned to a dog-training programme group (n = 30) and a control group (n = 23) that engaged in other training programmes (e.g. cooking, hairstyling, etc.). Both groups were evaluated at baseline and following 12-months by The Clinician-Administered PTSD Scale for DSM-5 in Children and Adolescents (CAPS-CA-5) and Beck-Depression Inventory (BDI). Additionally, we physiologically measured both emotional and attention dysregulation. Results: Post-12-months training, a significant alleviation of PTSD symptomatology accompanied by lower depression severity was observed in the dog-training group, compared with a insignificant recovery in the control group. Furthermore, improved emotional and attentional regulation was observed in the dog-training group. Measuring the dogs' behaviour revealed increased anxiety and decreased selective attention performance, which was inversely correlated with the beneficial effects observed in the dog-training programme group. Conclusions: Our findings emphasize the role of emotional and attentional regulations on the dog-handler interface, as evidence-based support for the beneficial effects of the dog-training programme, as either a non-pharmacological intervention or as complementary to anti-depressants treatment of PTSD. Though pharmacological treatments increase the patients' well-being by treating certain PTSD symptoms, our suggested dog-training programme seems to influence the PTSD diagnostic status, thus may be implemented in civilians and veterans with PTSD.

Antecedentes: Los síntomas de trastorno de estrés postraumático (TEPT) incluyen re-experimentación, evitación, hiperalerta y déficits cognitivos, reflejando desregulación tanto emocional como cognitiva. En los últimos años, se demostró que los enfoques no farmacológicos y específicamente la terapia asistida por animales son beneficiosos para una variedad de trastornos como el Trastorno por Déficit Atencional e Hiperactividad, el Trastorno del Espectro Autista y el TEPT. Sin embargo, poco se menciona en la literatura acerca de los efectos recíprocos de la interacción animal-humano.Objetivo: Evaluar los efectos de un programa de adiestramiento canino de un año en la sintomatología de TEPT en los jóvenes con TEPT y en el comportamiento de los perros.Métodos: Cincuenta y tres adolescentes, previamente expuestos a trauma interpersonal, fueron diagnosticados clínicamente con TEPT y asignados a un grupo de programa de adiestramiento canino (n = 30) y a un grupo control (n = 23) que participaron en otros programas de adiestramiento (ej., cocinar, peluquería, etc). Ambos grupos fueron evaluados al inicio y después de 12 meses mediante la Escala de TEPT administrada por el Clínico del DSM-5 en niños y adolescentes (CAPS-CA-5 por sus siglas en inglés) y el Inventario de Depresión de Beck (BDI). Adicionalmente, medimos fisiológicamente la desregulación emocional y de la atención.Resultados: Después del entrenamiento de 12 meses, se observó un alivio significativo de la sintomatología de TEPT junto con una disminución de la severidad de la depresión en el grupo de adiestramiento canino, comparado con una recuperación insignificante en el grupo control. Además, se observó una mejoría en la regulación emocional y de la atención en el grupo de adiestramiento canino. La medición del comportamiento de los perros reveló un aumento de la ansiedad y disminución del rendimiento de la atención selectiva, que se correlacionó inversamente con los efectos beneficiosos observados en el grupo del programa de adiestramiento canino.Conclusiones: Nuestros hallazgos enfatizan el rol de la regulación emocional y de atención en la interfaz del entrenador de perros, como soporte basado en la evidencia para los efectos beneficiosos del programa de adiestramiento canino, tanto como tratamiento no farmacológico como complementario al tratamiento antidepresivo del TEPT. Aunque los tratamientos farmacológicos fomentan el bienestar de los pacientes al tratar ciertos síntomas del TEPT, nuestro programa de adiestramiento canino sugerido parece influir en el estado diagnóstico de TEPT, por lo que puede implementarse en civiles y veteranos con TEPT.

Trends in Psychiatric Emergency Department Visits in Northern Israel During the COVID-19 Outbreak.

Background: During the spread of coronavirus disease (COVID-19), mandatory quarantines increased social isolation and anxiety, with inevitable consequences on mental health and health seeking behavior. We wished to estimate those trends. Methods: We examined all psychiatric visits to the emergency department (ED) during March, April 2020, compared to identical months in 2018, 2019. We evaluated both number and nature of referrals. Results: Throughout the years, psychiatric referrals comprised about 5% of the total number of ED visits. In March-April 2020, 30% decreases were observed in overall ED visits and in psychiatric referrals in the ED. Compared to 2018-2019, in 2020, the proportions of these diagnoses were higher: anxiety disorders (14.5 vs. 5.4%, p < 0.001), personality disorders (6.7 vs. 3.2%, p = 0.001), psychosis (9.5 vs. 6.7%, p = 0.049), post-traumatic stress disorder (3.2 vs. 1.5%, p = 0.023). Compared to 2018-2019, in 2020, proportions were lower for adjustment disorder (5.8 vs. 8.9%, p = 0.036) and for consultation regarding observation (11.7 vs. 31.6%, p < 0.001). Differences were not observed between 2018-2019 and 2020 in the proportions of other diagnoses including suicide and self-harm disorders. Referrals concerning suicide and self-harm in a rural hospital and community clinic were 30% lower in the COVID-19 lockdown than in the same months in 2018, 2019. Conclusion: Psychiatric ED visits decreased by the same proportion as overall visits to the ED, apparently driven by fears of COVID-19. Referrals relating suicidality and self-harm shown nominal decrease, but their proportioned share remained constant. Increased anxiety and delayed care may eventually lead to increased mental health needs.

Preliminary effects of bupropion and the promoter region (HTTLPR) serotonin transporter (SLC6A4) polymorphism on smoking behavior in schizophrenia.

In the current study, we investigated how individual variants in the serotonin promoter gene, previously associated with smoking cessation and linked to anxiety-related personality traits, were associated with individual differences in responsiveness to bupropion and cognitive behavioral therapy (CBT) in a clinical population. We hypothesize that subjects with the long allele may be less responsive to treatment. Altogether 61 schizophrenic patients (46 M, 15 F) on stable neuroleptic medication were initially enrolled in a smoking reduction program (prospective, double-blind, placebo-controlled) including cognitive behavioral therapy plus placebo or CBT plus bupropion. Additionally, subjects were genotyped for a polymorphism in the serotonin transporter (SLC6A4). Thirty-two subjects (23 M, 9 F) completed a 14-week course of treatment. While both groups of subjects demonstrated significant reductions in smoking behavior due to CBT, subjects receiving bupropion did not show significant differences in smoking behavior when compared to placebo. In addition, analysis by SPSS repeated measures multivariate showed a significant sex by SLC6A4 genotype interaction on the number of cigarettes smoked. Only male subjects with at least one short promoter region allele (short/short and short/long combined) showed a reduction in cigarette consumption as a result of treatment. This study provides preliminary evidence of how polymorphisms in the serotonin transporter can be informative in predicting individual responses to smoking reduction therapy.

The effects of music relaxation on sleep quality and emotional measures in people living with schizophrenia.

The aim of the present study was to examine the effects of music relaxation on insomnia and emotional measures in people living with schizophrenia. Twenty-four people living with schizophrenia participated in the study. The study involved a 7-day running-in no-treatment period, followed by a 7-day experimental period. Treatment consisted of music relaxation played at bedtime. During each of these periods, participants' sleep was continuously monitored with a wrist actigraph, and participants completed a wide spectrum of questionnaires. Results showed an improvement in sleep latency and sleep efficiency after the music relaxation was played. Likewise, music relaxation was shown to improve participants' total psychopathology score (PANSS) as well as their level of depression. Moreover, a significant correlation was found between reduction in level of situational anxiety and improvement in sleep efficiency. The findings suggest the beneficial effect of music relaxation as a treatment both for insomnia and for emotional measures in people living with schizophrenia.

Pilot controlled trial of D-serine for the treatment of post-traumatic stress disorder.

Enhancement of neurotransmission mediated at N-methyl-D-aspartate subtype of glutamate receptors (NMDAR) may be beneficial in post-traumatic stress disorder (PTSD). d-serine (DSR) is an endogenous full agonist at the NMDAR-associated glycine modulatory site. Twenty-two chronic PTSD outpatients were randomly assigned to participate in a 6-wk double-blind, placebo-controlled, crossover trial with 30 mg/kg x d DSR used as monotherapy or add-on pharmacotherapy. Outcome was assessed using the Clinician-Administered PTSD scale (CAPS), Hamilton Anxiety (HAMA) and Depression (HAMD) scales and the civilian version of the Mississippi Scale for Combat-Related PTSD (MISS). DSR treatment was well tolerated and resulted in significantly (p=0.03) increased DSR serum levels. Compared with placebo administration, DSR treatment resulted in significantly reduced HAMA (p=0.007) and MISS (p=0.001) scores and a trend (p=0.07) towards improved CAPS total scores. These preliminary findings indicate that NMDAR glycine site-based pharmacotherapy may be effective in PTSD and warrant larger-sized clinical trials with optimized DSR dosages.

Psychiatrists' attitude towards the use of clozapine in the treatment of refractory schizophrenia: A nationwide survey.

OBJECTIVES: Clozapine is the most effective treatment for refractory schizophrenia, yet it remains underused in clinical practice. The current study examined the awareness, familiarity and attitude of a nationwide sample of Israeli psychiatrists regarding the use of clozapine. METHODS: Data were collected using questionnaires, completed by 295 psychiatrists. Participants were asked to score questions regarding clozapine procedures; familiarity with guidelines, drug properties, prescription and attitude towards specialized clozapine resources. RESULTS: About half (53.3%) of the psychiatrists reported initiating treatment with clozapine according to the guidelines, whereas 33% reported that they administered clozapine only after three or more unsuccessful antipsychotic treatments. Surprisingly, availability of specialized resources for clozapine treatment (such as clozapine clinics) was associated with delayed initiation of clozapine treatment, and a lower rate of clozapine administration. Barriers to clozapine use included concerns about patient adherence, side effects and partial compliance with the required blood monitoring. CONCLUSIONS: Delaying or avoiding clozapine treatment to potentially eligible patients, despite familiarity with the drug efficacy and treatment guidelines, is a major mental health concern. However, executive allocation of resources to support the use of clozapine may be ineffective in promoting clozapine use.

Immediate and brief intervention after suicide attempts on patients without major psychiatric morbidity-A pilot study in northern Israel.

BACKGROUND: Suicide Prevention is an ongoing task for mental health services. This article describes a pilot program for suicide prevention that took place in two districts in Israel from 2009 to 2012. The program targeted specific population, patients in high-risk for suicide, without major mental illness or previous association with the mental health system. In that group many suicide attempts were due to stressful life events. METHODS: Patients who performed a suicide attempt or were considered high-risk for suicide were referred to the project. The first contact took place up to 24 h after the referral and included a phone call with suggestion for further intervention. If he was willing, the patient was invited to a serious of 8-12 meetings with a therapist that focused on "crisis intervention" techniques. RESULTS: 212 subjects were referred to the project. Three quarters of the referrals were females. Most of them were of Jewish nationality, however, the percentage of Druze in the program's population was higher than their percentage of general population. Only 137 continued participation after the initial phone call, people of Jewish nationality were more willing to continue the intervention. During the intervention there was a decline in suicide rates in the participating districts. CONCLUSIONS: The pilot program exhibits promising preliminary results, it is interesting to examine the difference in participation between different ethnic groups. Since the sample size is small, there is a need to continue the program on a larger scale.

Use of information and communication technologies among individuals with and without serious mental illness.

Growing interest surrounds the use ofinformation and communication technologies (ICTs) for mental-health-related purposes, yet little is known about rates of ICT use among the psychiatric population and those with severe mental illness. This study examines ICT accessibility among the psychiatric population, focusing on serious and non-serious mental illness (SMI and non-SMI). Patients (N = 427) from all service branches of the Psychiatry Department at Emek Medical Centerwere recruited orally or through advertisement. Responders completed a self-report survey regarding accessibility and use of ICTs (i.e., computer, internet, Facebook, mobile phone, smartphone). Results revealed that 59.3% of respondents used computers, 77.3% used the internet, 92.7% owned a mobile phone, 67.9% owned a smartphone, and 63% used Facebook. Over half of participants who used ICTs reported doing so at least once per day. SMI and non-SMI respondents differed significantly in their use and access to a computer, the internet, Facebook, and smartphones. Results suggest that mental illness is not a barrier to using and accessing technology; however, when differentiating between SMI and non-SMI, illness severity is a barrier to potential ICT utilization. These results may encourage policy makers to design ICTs that suit the needs of individuals with SMI.

Sensory profiles in unipolar and bipolar affective disorders: Possible predictors of response to antidepressant medications? A prospective follow-up study.

INTRODUCTION: Sensory processing patterns have been proposed as a stable dimension able to characterize individuals with major affective disorders, but to what extent specific impairments in sensory processing may be involved in the pathophysiology of these conditions is poorly understood. We aimed to explore which sensory profiles may better respond to psychoactive medications, with particular regard to antidepressants, according to depression, alexithymia, and hopelessness levels. METHODS: A total of 402 outpatients who received maintenance treatment and were in stable psychopathological conditions were recruited and completed the Adolescent/Adult Sensory Profile (AASP), Toronto Alexithymia Scale (TAS-20), second version of the Beck Depression Inventory (BDI-II), and Beck Hopelessness Scale (BHS) according to a longitudinal prospective study design including three time points of measurements. RESULTS: Subjects with abnormally reduced sensory seeking, hypersensitivity, enhanced sensory avoidance, and lower ability to register information better responded to antidepressant medications according to their reduced depression levels. Similarly, participants with lower registration better responded to antidepressants as reported by lower hopelessness levels. Regression analyses revealed that the use of antidepressants was the first variable able to predict depression, hopelessness, and alexithymia levels at baseline, and after three and six months of treatment, respectively, but the pattern of sensory sensitivity contribute to the prediction of depression and hopelessness. This pattern together with low registration predicted changes in alexithymia levels. LIMITATIONS: The study was limited by the modest sample size at the follow-up assessment points. DISCUSSION: Exploring sensory processing patterns may provide intriguing insights into specific illness characteristics and treatment response.

A Pilot Study of Possible Easy-to-Use Electrophysiological Index for Early Detection of Antidepressive Treatment Non-Response.

INTRODUCTION: The evaluation of response to pharmacological treatment in MDD requires 4-8 weeks. Therefore, the ability to predict response, and especially lack of response to treatment, as early as possible after treatment onset or change, is of prime significance. Many studies have demonstrated significant results regarding the ability to use EEG and ERP markers, including attention-associated markers such as P300, for early prediction of response to treatment. But these markers are derived from long EEG/ERP samples, often from multiple channels, which render them impractical for frequent sampling. METHODS AND RESULTS: We developed a new electrophysiological attention-associated marker from a single channel (two electrodes), using 1-min samples with auditory oddball stimuli. This work presents an initial evaluation of the ability to use this marker's dynamics between repetitive measures for early (<2 weeks) differentiation between responders and non-responders to antidepressive treatment, in 26 patients with various levels of depression and heterogeneous treatment interventions. The slope of change in the marker between early consecutive samples was negative in the non-responders, but not in the responders. This differentiation was stronger for patients suffering from severe depression (p < 0.001). CONCLUSION: This pilot study supports the feasibility of the EEG marker for early recognition of treatment-resistant depression. If verified in large-scale prospective studies, it can contribute to research and clinical work.

Relation of plasma glycine, serine, and homocysteine levels to schizophrenia symptoms and medication type.

OBJECTIVE: Altered glycine and homocysteine levels may contribute to N-methyl-D-aspartate receptor dysfunction in schizophrenia. The authors measured plasma levels of these amino acids in a group of patients with chronic schizophrenia and related them to the patients' symptom profiles and types of antipsychotic medication. METHOD: Plasma levels of amino acids in 94 patients with schizophrenia were compared with those in 34 age- and sex-matched normal subjects. The Positive and Negative Syndrome Scale was used to evaluate the patients' psychopathology. RESULTS: Plasma glycine levels and glycine-serine ratios were lower and homocysteine levels were higher in patients than in comparison subjects. Low glycine levels correlated with a greater number of negative symptoms. The glycine-serine ratios of normal subjects and patients being treated with clozapine did not differ significantly. CONCLUSIONS: These findings support the hypothesis that altered levels of glycine and homocysteine may coexist in patients with schizophrenia and contribute to pathophysiological aspects of this illness.

Assessment of participation in physical activities and relationship to socioeconomic and health factors. The controversial value of self-perception.

Physician counseling on physical activities for sedentary people is usually based on anamneses. The aim of the present study was to investigate the accuracy of self-perception of participation in physical activities, and the correlation of physical activity with background factors. A random sample of 276 individuals aged 20-65 years completed a detailed questionnaire on type and intensity of physical activity and associated socioeconomic and health factors. Physical activities were divided into work, leisure-time, and sports and rated according to Baecke's four-item index. In addition, subjects answered a yes/no item that resembled the general question regarding physical activity usually asked by physicians in a typical anamnesis. About half of the population was found to lead a sedentary life-style. The lower the level of education, the greater the physical activity at work. Males had a higher sports index than females. Interestingly, 1.3% of those with a high questionnaire score reported on the anamnesis question that they did not engage in regular physical activity, whereas 17.5% with a low questionnaire score answered "yes" to the last item. In conclusion, self-reports on physical activity may be inaccurate and to ensure proper counseling, primary care physicians must place greater weight on the patient history.

[Difficulties in diagnosis and localization of recurrent medullary thyroid carcinoma].

Recurrent and residual medullary thyroid carcinoma (MTC) are common in patients following primary surgical resection. Difficulty arises in performing precise localization of the tumor because of anatomical distortion of the neck structures following surgery. To date, no modality has been shown superior to others in the diagnosis of recurrent or residual MTC, and the issue is currently under debate in the literature. We report a case in which secondary recurrence of MTC was detected and localized using a novel combination of preoperative and intraoperative radionuclide imaging, and a method of preventing intraoperative damage to the recurrent laryngeal nerve in the anatomically disrupted neck. To our knowledge, this is the first report of a combination of these three modalities in detection and localization of recurrent MTC, while minimizing the possibility for nerve injury during the operative procedure. Such a therapeutic strategy may prove useful in the management of patients who have previously undergone neck surgery and suffer from anatomical distortion of normal neck structures.

The Effects of Acupuncture Treatment on Sleep Quality and on Emotional Measures among Individuals Living with Schizophrenia: A Pilot Study.

Purpose. To examine the effects of acupuncture on sleep quality and on emotional measures among patients with schizophrenia. Methods. Twenty patients with schizophrenia participated in the study. The study comprised a seven-day running-in no-treatment period, followed by an eight-week experimental period. During the experimental period, participants were treated with acupuncture twice a week. During the first week (no-treatment period) and the last week of the experimental period, participants filled out a broad spectrum of questionnaires and their sleep was continuously monitored by wrist actigraph. Results. A paired-sample t-test was conducted comparing objective and subjective sleep parameters manifested by participants before and after sequential acupuncture treatment. A significant effect of acupuncture treatment was observed for seven objective sleep variables: sleep onset latency, sleep percentage, mean activity level, wake time after sleep onset, mean number of wake episodes, mean wake episode and longest wake episode. However, no significant effects of acupuncture treatment were found for subjective sleep measures. Likewise, the results indicate that acupuncture treatment improved psychopathology levels and emotional measures, that is, depression level and anxiety level. Conclusions. Overall, the findings of this pilot study suggest that acupuncture has beneficial effects as a treatment for insomnia and psychopathology symptoms among patients with schizophrenia.

The effects of music relaxation and muscle relaxation techniques on sleep quality and emotional measures among individuals with posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD), an anxiety disorder with lifetime prevalence of 7.8%, is characterized by symptoms that develop following exposure to traumatic life events and that cause an immediate experience of intense fear, helplessness or horror. PTSD is marked by recurrent nightmares typified by the recall of intrusive experiences and by extended disturbance throughout sleep. Individuals with PTSD respond poorly to drug treatments for insomnia. The disadvantages of drug treatment for insomnia underline the importance of non-pharmacological alternatives. Thus, the present study had three aims: first, to compare the efficiency of two relaxation techniques (muscular relaxation and progressive music relaxation) in alleviating insomnia among individuals with PTSD using both objective and subjective measures of sleep quality; second, to examine whether these two techniques have different effects on psychological indicators of PTSD, such as depression and anxiety; and finally, to examine how initial PTSD symptom severity and baseline emotional measures are related to the efficiency of these two relaxation methods. Thirteen PTSD patients with no other major psychiatric or neurological disorders participated in the study. The study comprised one seven-day running-in, no-treatment period, followed by two seven-day experimental periods. The treatments constituted either music relaxation or muscle relaxation techniques at desired bedtime. These treatments were randomly assigned. During each of these three experimental periods, subjects' sleep was continuously monitored with a wrist actigraph (Ambulatory Monitoring, Inc.), and subjects were asked to fill out several questionnaires concerned with a wide spectrum of issues, such as sleep, depression, and anxiety. Analyses revealed a significant increase in objective and subjective sleep efficiency and a significant reduction in depression level following music relaxation. Moreover, following music relaxation, a highly significant negative correlation was found between improvement in objective sleep efficiency and reduction in depression scale. The study's findings provide evidence that music relaxation at bedtime can be used as treatment for insomnia among individuals with PTSD.