Access to diagnostic and therapeutic facilities for psychogenic nonepileptic seizures: An international survey by the ILAE PNES Task Force.

OBJECTIVE: Studies from a small number of countries suggest that patients with psychogenic nonepileptic seizures (PNES) have limited access to diagnostic and treatment services. The PNES Task Force of the International League Against Epilepsy (ILAE) carried out 2 surveys to explore the diagnosis and treatment of PNES around the world. METHODS: A short survey (8 questions) was sent to all 114 chapters of the ILAE. A longer survey (36 questions) was completed by healthcare professionals who see patients with seizures. Questions were separated into 5 sections: professional role, diagnostic methods, management, etiology, and access to health care. RESULTS: Responses were received from 63 different countries. The short survey was completed by 48 ILAE chapters, and the long survey by 1098 health professionals from 28 countries. PNES were recognized as a diagnostic and therapeutic problem in all countries. Trauma and mental health issues were most commonly recognized as etiologic factors. There was a clear relationship between income and access to diagnostic tests and expertise. Psychological therapy was most commonly considered the treatment of choice. Although financial difficulties were the most commonly reported problem with service access in low-income countries, in all countries stigma, lack of popular awareness, and lack of information posed challenges. SIGNIFICANCE: This global provider survey demonstrates that PNES are a health problem around the world. Health care for PNES could be improved with better education of healthcare professionals, the development of reliable and simple diagnostic procedures that do not rely on costly tests, and the provision of accessible information.

Water Stress from High-Volume Hydraulic Fracturing Potentially Threatens Aquatic Biodiversity and Ecosystem Services in Arkansas, United States.

Demand for high-volume, short duration water withdrawals could create water stress to aquatic organisms in Fayetteville Shale streams sourced for hydraulic fracturing fluids. We estimated potential water stress using permitted water withdrawal volumes and actual water withdrawals compared to monthly median, low, and high streamflows. Risk for biological stress was considered at 20% of long-term median and 10% of high- and low-flow thresholds. Future well build-out projections estimated potential for continued stress. Most water was permitted from small, free-flowing streams and "frack" ponds (dammed streams). Permitted 12-h pumping volumes exceeded median streamflow at 50% of withdrawal sites in June, when flows were low. Daily water usage, from operator disclosures, compared to median streamflow showed possible water stress in 7-51% of catchments from June-November, respectively. If 100% of produced water was recycled, per-well water use declined by 25%, reducing threshold exceedance by 10%. Future water stress was predicted to occur in fewer catchments important for drinking water and species of conservation concern due to the decline in new well installations and increased use of recycled water. Accessible and precise withdrawal and streamflow data are critical moving forward to assess and mitigate water stress in streams that experience high-volume withdrawals.

Unconventional Oil and Gas Spills: Risks, Mitigation Priorities, and State Reporting Requirements.

Rapid growth in unconventional oil and gas (UOG) has produced jobs, revenue, and energy, but also concerns over spills and environmental risks. We assessed spill data from 2005 to 2014 at 31 481 UOG wells in Colorado, New Mexico, North Dakota, and Pennsylvania. We found 2-16% of wells reported a spill each year. Median spill volumes ranged from 0.5 m3 in Pennsylvania to 4.9 m3 in New Mexico; the largest spills exceeded 100 m3. Seventy-five to 94% of spills occurred within the first three years of well life when wells were drilled, completed, and had their largest production volumes. Across all four states, 50% of spills were related to storage and moving fluids via flowlines. Reporting rates varied by state, affecting spill rates and requiring extensive time and effort getting data into a usable format. Enhanced and standardized regulatory requirements for reporting spills could improve the accuracy and speed of analyses to identify and prevent spill risks and mitigate potential environmental damage. Transparency for data sharing and analysis will be increasingly important as UOG development expands. We designed an interactive spills data visualization tool ( http://snappartnership.net/groups/hydraulic-fracturing/webapp/spills.html ) to illustrate the value of having standardized, public data.

A multicenter evaluation of a brief manualized psychoeducation intervention for psychogenic nonepileptic seizures delivered by health professionals with limited experience in psychological treatment.

RATIONALE: The aim of this study was to add to our understanding of the impact of psychoeducation on patients' acceptance of the diagnosis of psychogenic nonepileptic seizures (PNESs), the frequency of their seizures, and their quality of life. The study also aimed to evaluate the effectiveness of brief manualized psychoeducation interventions for PNESs, delivered by a more diverse range of clinicians and in a wider range of treatment settings. METHOD: The final sample consisted of 25 patients diagnosed with PNESs by a neurologist specializing in the treatment of seizure disorder and referred to the psychotherapy service. The study included patients from four centers, using a manualized psychoeducation intervention delivered over 4 sessions by specialist epilepsy nurses and assistant psychologists. All patients completed self-measure questionnaires for Seizure Frequency, Impaired Functioning (WSAS), Psychological Distress (CORE-OM), Illness Perception (BIPQ), Health-Related Quality of Life: general (ED-QOL) and epilepsy-specific (NewQOL-6D), Symptom Attribution, and patient's perception of usefulness and relevance of the intervention. All measures were collected at baseline and after the completion of the fourth session. RESULTS: All measures improved from baseline to postintervention, but this improvement was only significant for CORE-OM (p<.05) and BIPQ (p<.01). Out of the 25 patients who completed the intervention information, 6 out of 25 (24%) had been seizure-free for the past month, and an additional 6 out of 25 (24%) had achieved seizure frequency reduction. Consequently, upon completion of the intervention, 12 out of 25 patients (48%) were either seizure-free or experienced fewer seizures compared with the start of the intervention. CONCLUSION: The evidence suggests that brief manualized psychoeducation intervention can reduce PNES frequency, improve the psychological distress, and have an effect on patients' illness perceptions that should help them engage with a more extended psychotherapy program if that was necessary. The intervention was carried out successfully by staff with relatively little training in delivering psychological interventions. Further controlled studies are required to provide proof of efficacy.

The capacity of states to govern shale gas development risks.

The development of natural gas and oil from unconventional formations in the United States has grown substantially in recent years and has created governance challenges. In light of this recent growth, and increasing attention to global shale gas resources, the successes and failures of governance efforts in this country serve as important lessons for other nations that have their own unconventional petroleum resources and are beginning to move forward with development, thus calling for a more in-depth examination of the laws governing shale gas development and their implementation. Governance includes both the substance of laws and the activities of entities that implement and influence laws, and in the case of oil and gas, states are primarily responsible for risk governance. Nongovernmental actors and industry also work with states to shape and implement regulations and standards. This Policy Analysis introduces the role of various actors in U.S. shale gas governance, explaining why the states are primarily responsible for risk governance, and explores the capacity of states to conduct governance, examining the content of their laws and the strength of their regulatory entities. The Analysis concludes that states are, to a degree, addressing the changing risks of development. Gaps remain in the substance of regulations, however, and many states appear to lack adequate support or policies for training industry in compliance matters, monitoring activity at sites, prioritizing certain types of regulatory violations that pose the highest risks, enforcing laws, and ensuring that the public is aware of inspections and enforcement and can therefore monitor state activity.

The Relevance of Cognitive Behavioral Models of Post-Traumatic Stress Following Child Maltreatment: A Systematic Review.

While it is known that young people exposed to maltreatment or abuse are at elevated risk of developing post-traumatic stress disorder (PTSD), much of our current knowledge of mechanisms that link trauma to childhood PTSD is based on single-incident, often noninterpersonal, trauma. Theoretical models highlight psychological processes of appraisals, memory, and coping as important for the development of PTSD. The aim of this review was to synthesize the literature on the role of these key psychological processes in relation to PTSD in maltreated children and teens. Studies were included if they (1) identified a sample of maltreated individuals, ≤18 years old; (2) measured (a) trauma memory, (b) appraisals, or (c) post-trauma cognitive or behavioral responses; and (3) measured PTSD symptoms. The systematic search of three electronic databases (American Psychological Association PsychNet, PubMed, and Published International Literature on Traumatic Stress) resulted in the inclusion of 36 papers, which described 31 studies and 33 unique samples. The review found cognitive behavioral models of PTSD appeared appropriate for understanding outcomes following maltreatment, but further research is needed on all processes, particularly trauma memory. Overall, there remain significant gaps in our knowledge of how psychological processes link maltreatment to PTSD. There is limited evidence concerning how maltreatment-related characteristics (e.g., chronicity, duration, and type of abuse) influence psychological processes and in turn affect outcomes. This review recommends further research in this area and suggests that, at the very least, comprehensive assessment should be conducted with all young people reporting maltreatment to identify appraisals and coping strategies that will potentially impact on their ongoing adjustment.

Factors associated with progression to infection in methicillin-resistant Staphylococcus aureus-colonized, critically ill neonates.

OBJECTIVE: To identify factors associated with development of symptomatic infection in infants colonized with methicillin-resistant Staphylococcus aureus (MRSA) in the Neonatal Intensive Care Unit (NICU). STUDY DESIGN: This case-control study was performed at St. Louis Children's Hospital NICU from 2009 to 2019. The MRSA-colonized infants who developed symptomatic MRSA infection (cases) were matched 1:3 with MRSA-colonized infants who did not develop infection (controls). Demographics and characteristics of NICU course were compared between groups. Longitudinal information from subsequent hospitalizations was also obtained. RESULTS: Forty-two infected cases were compared with 126 colonized-only controls. Cases became colonized earlier in their NICU stay, were less likely to have received mupirocin for decolonization, and had a longer course of mechanical ventilation than controls. Longitudinally, cases had a more protracted NICU course and were more likely to require hospital readmission. CONCLUSION: Progression from MRSA colonization to symptomatic infection is associated with increased morbidity and may be mitigated through decolonization.

Priming attachment security improves attitudes towards a range of therapies.

We sought to understand how attachment orientation influenced attitudes towards different types of psychological therapies. In two studies, we (1) examined attachment orientation as a predictor of attitudes towards different therapies and (2) tested whether attachment security priming could improve attitudes. Study 1 (n = 339) found associations between attachment orientation and attitudes towards, and likelihood of using different therapies. Positive and negative attitudes about different therapies mediated the relationship between attachment avoidance and likelihood of use. Study 2 (n = 412) showed that primed security (vs. neutral prime) improved attitudes towards relational, non-relational and distanced-relational therapies for those with a fearful-avoidant attachment orientation. For relational and distanced-relational therapies, the mechanism of this effect was increased cognitive openness. Attachment orientation is a determinant of therapy attitudes and anticipated help-seeking behaviour. Priming security may promote open-minded decision-making about some therapies. Findings are discussed with relevance to attachment theory, research and clinical practice.

Unconventional oil and gas spills: Materials, volumes, and risks to surface waters in four states of the U.S.

Extraction of oil and gas from unconventional sources, such as shale, has dramatically increased over the past ten years, raising the potential for spills or releases of chemicals, waste materials, and oil and gas. We analyzed spill data associated with unconventional wells from Colorado, New Mexico, North Dakota and Pennsylvania from 2005 to 2014, where we defined unconventional wells as horizontally drilled into an unconventional formation. We identified materials spilled by state and for each material we summarized frequency, volumes and spill rates. We evaluated the environmental risk of spills by calculating distance to the nearest stream and compared these distances to existing setback regulations. Finally, we summarized relative importance to drinking water in watersheds where spills occurred. Across all four states, we identified 21,300 unconventional wells and 6622 reported spills. The number of horizontal well bores increased sharply beginning in the late 2000s; spill rates also increased for all states except PA where the rate initially increased, reached a maximum in 2009 and then decreased. Wastewater, crude oil, drilling waste, and hydraulic fracturing fluid were the materials most often spilled; spilled volumes of these materials largely ranged from 100 to 10,000L. Across all states, the average distance of spills to a stream was highest in New Mexico (1379m), followed by Colorado (747m), North Dakota (598m) and then Pennsylvania (268m), and 7.0, 13.3, and 20.4% of spills occurred within existing surface water setback regulations of 30.5, 61.0, and 91.4m, respectively. Pennsylvania spills occurred in watersheds with a higher relative importance to drinking water than the other three states. Results from this study can inform risk assessments by providing improved input parameters on volume and rates of materials spilled, and guide regulations and the management policy of spills.

Do patients want choice? An observational study of neurology consultations.

OBJECTIVES: To determine how often patients are given choice in neurology outpatient consultations and whether choice is associated with greater patient satisfaction. METHODS: Prospective study in outpatient clinics in two United Kingdom centres. Interactions between 14 neurologists and 223 patients were studied. Participating doctors and patients completed post-appointment questionnaires asking whether choice had been offered/perceived. Patients completed the Medical Interview Satisfaction Scale 21 (MISS-21). RESULTS: Choice was reported after most encounters (patients 71.8%, neurologists 67.9%). Patients and Neurologists failed to agree about whether choice was offered after 32% of consultations. Choice was not associated with increased patient satisfaction. In fact, satisfaction was greater when no choice had been offered (p=0.05). Satisfaction scores were also greater when doctors were more certain about the diagnosis and when symptoms were considered explained by a medical condition (p≤0.001). CONCLUSIONS: Choice featured in the majority of clinical interactions but clinicians and patients often disagreed whether this was the case. Choice was not associated with greater patient satisfaction. PRACTICE IMPLICATIONS: Clinicians need to be very explicit if they want patients to know that they are being given choices. Choice is not necessarily valued by patients in all clinical interactions.

New insights into psychogenic nonepileptic seizures 2011-2014.

PURPOSE: There has been a rapid increase in the rate of publications about psychogenic nonepileptic seizures (PNES). This review summarises insights from the 50 most important original articles about PNES published since 2011 and describes the advances made in the understanding of PNES over the last 3 years. METHOD: We carried out a systematic literature search of all English language publications about PNES published between October 2011 and October 2014 on Scopus, Ovid Medline and Web of Knowledge, and inspected all abstracts. Having excluded all review articles, case reports, conference abstracts, articles exploring PNES in children, and articles not actually focussing on PNES, we considered 150 papers for inclusion in this review. We assessed the quality of the identified studies and used expert judgement to identify the 50 most important publications from the review period and composed a narrative review based on these original papers. RESULTS: Almost one half of the studies initially identified only provided Class 4 evidence. Recent work has provided more support for a biopsychosocial account of PNES. It has illustrated the heterogeneity of PNES, identifying varying and distinct psychological profiles of individuals with this disorder. These findings suggest that intervention needs to be flexible or adaptive if it is appropriately to target the different mechanisms which may give rise to PNES. Several educational and psychotherapeutic interventions for PNES have been described, but sufficiently powered randomised controlled trials are yet to be undertaken. Recent research using social, economic and quality of life indicators has provided further evidence of the societal and individual burden of PNES. CONCLUSION: The research into PNES published over the last 3 years has deepened our understanding of the condition as a biopsychosocial disorder which is neither a "physical" nor a "psychological" condition. A number of small studies have demonstrated the potential of educational and psychotherapeutic treatments, but rigorous and sufficiently large trials still need to be conducted to determine the effectiveness of these interventions.