[Treatment of refractory aggressiveness by amygdalotomy and posteromedial hypothalamotomy by radiofrequency]. / Tratamiento de la agresividad refractaria mediante amigdalotomia e hipotalamotomia posteromedial por radiofrecuencia.

INTRODUCTION: Since, under certain circumstances, defensive or attacking behaviours display a pattern of motor dominance, as observed in subjects who participate in contact or fighting sports, aggressive behaviour was considered to have a dominant motor pattern. With the aim of preventing the functional problems reported with bilateral lesion procedures involving both the central nucleus of the amygdala and the posteromedial hypothalamus, the decision was made to combine them; thus, an amygdalotomy of the central nucleus of the amygdala and a posteromedial hypothalamotomy were to be performed simultaneously and unilaterally, on the basis of the motor dominance of the patient determined by means of the Edinburgh test. PATIENTS AND METHODS: This study describes the surgical experience in a series of nine patients diagnosed with refractory neuroaggressive syndrome. As part of the study protocol, a magnetic resonance brain scan was performed to rule out the presence of neoplasms, vascular diseases, infections and degenerative disorders. The degree of aggressiveness was quantified using Yudofsky's Overt Aggression Scale. Additionally, manual dominance was determined by means of the Edinburgh test. RESULTS AND CONCLUSIONS: Good control of aggressiveness was seen immediately. In some cases it was necessary to reduce the antipsychotic or benzodiazepine medication, as it was seen to increase aggressiveness. Only one case required a second surgical intervention. Follow-up was achieved in 100% of the cases at 24 months and 78% at 36 months.

TITLE: Tratamiento de la agresividad refractaria mediante amigdalotomia e hipotalamotomia posteromedial por radiofrecuencia.Introduccion. Dado que, en algunas circunstancias, las conductas defensivas o de ataque muestran un patron de dominancia motora, tal como se observa en los sujetos dedicados a los deportes de contacto o de lucha, se considero que la conducta agresiva tiene un patron motor dominante. Con el fin de evitar los problemas funcionales descritos con los procedimientos de lesion bilateral tanto del nucleo central de la amigdala como del hipotalamo posteromedial, se decidio combinarlos; es decir, realizar amigdalotomia del nucleo central de la amigdala e hipotalamotomia posteromedial de manera unilateral y simultanea, basandose en la dominancia motora del paciente mediante la prueba de Edimburgo. Pacientes y metodos. Este estudio muestra la experiencia quirurgica en una serie de nueve pacientes con el diagnostico de sindrome neuroagresivo resistente al tratamiento farmacologico. Dentro del protocolo de estudio, se les realizo resonancia magnetica cerebral para descartar la presencia de neoplasias, enfermedades vasculares, infecciones y trastornos degenerativos. El grado de agresividad se cuantifico mediante la escala global de agresividad de Yudofsky. Adicionalmente, se determino la dominancia manual a traves de la prueba de Edimburgo. Resultados y conclusiones. El buen control de la agresividad se observo de modo inmediato. En algunos casos fue necesario reducir la medicacion de antipsicoticos o benzodiacepinas, ya que aumentaban la agresividad. Solo un caso requirio una segunda cirugia. Se logro seguimiento del 100% de los casos en 24 meses y del 78% en 36 meses.

Assessing the effectiveness of integrated interventions: terminology and approach.

Integrated care is a term that embraces several concepts, all of which imply that the target patients have complex or chronic illness. There is an assumption that such patients require integrated care and benefit from it. Attempts to test this hypothesis have produced evidence of only modest benefit, and much of the evidence is conflicting. Demonstration of effectiveness of integrated interventions in the clinical setting has been less convincing. Often, interventions are introduced uncritically and without adequate follow-up of their effectiveness. More rigorous research is required on definitions, theoretic constructs,outcome measures, the science of data synthesis, and translation to the clinical setting. Recent developments in theoretic constructs in these areas give promise of better answers to the question, "What works for whom in what context?". Qualitative methodology should form part of this research.

Case and care complexity in the medically ill.

The authors have argued that complexity in general health care is increasingly prevalent because of the increase in patients who have multimorbid conditions, and the increased professional and technical possibilities of medicine. In the increasingly complex care systems, it is necessary-specifically when treating patients in need of integrated care by several providers-that an optimal match between case and care complexity be found in order to prevent poor outcomes in this vulnerable group. The authors discussed several approaches to case complexity that can be identified in the literature. Most of them seem unsuitable for adjusting case and care complexity, and inadequate for designing multidisciplinary care. Theoretic approaches to case complexity may be of interest, but did not result in clinically meaningful information. The INTERMED, which can be considered the first empirically based instrument to link case and care complexity, is an attempt to improve care delivery and outcomes for the complex medically ill.

Identifiers, or "red flags," of complexity and need for integrated care.

Because complex medical patients are a subgroup of the medical population and because complexity assessment involves extra effort, preselection of these patients through identifiers is necessary. There is no best identifier for complexity, and the one most suitable for the population served should be selected. This article provides a table with potential identifiers and discusses the difference between disease-oriented screening and treatment and a more generic approach such as complexity screening and complexity management.

Operationalizing integrated care on a clinical level: the INTERMED project.

During the last 10 years the INTERMED method has been developed as a generic method for the assessment of bio-psychosocial health risks and health needs and for planning of integrated treatment. The INTERMED has been conceptualized to counteract divisions and fragmentation of medical care. Designed to enhance the communication between patients and the health providers as well as between different professions and disciplines, the INTERMED is a visualized, action-oriented decision-support tool. This article presents various aspects of the INTERMED, such as its relevance, description, scoring, the related patient interview and treatment planning, scientific evaluation, implementation, and support for the method.

Reflections and perspectives.

Complex patients who have biopsychosocial comorbidities represent a major challenge for the current health care system. Unlike standard medical situations for which medical care can be based on an evidence-based approach, complex patients require a broader concept of care. As demonstrated throughout this issue, such an integrated approach that takes into account the concepts of case- and care complexity is not only possible, it is cost-effective. Integrated care, however, needs assessment tools and a communications-based approach that fosters exchange and collaboration between different medical disciplines and professions and patients.

Behavioral problems and tobacco use among adolescents in Central America and the Dominican Republic

Objectives: The purpose of this study was to examine the association between behavioral problems and tobacco use among adolescent students in six countries of Central America and in the Dominican Republic. Methods: Data were drawn from a multinational collaborative study that included questionnaire surveys of between 451 and 1 170 school-attending adolescents in each of the seven countries studied. Assessments were based on an adapted, Spanish-language version of the Drug Use Screening Inventory (DUSI). The conditional form of logistic regression was employed for analysis, matching students on type of school and area, with further statistical adjustments for sex, age, and selected risk factors. Results: Occurrence of tobacco use was observed to vary dramatically from country to country. Nevertheless, for the combined group of countries, the estimated odds of tobacco use in youths at the highest levels of behavioral problems was more than five times that for youths at the lowest levels, after controlling for sex, age, lack of participation in recreational activities, level of irritability, and levels of problems with school, family, and mental health. Country-specific analyses show that youths at the highest levels of behavioral problems have a consistently greater occurrence of tobacco use as compared to youths at the lowest levels of behavioral problems. Conclusions: These findings are concordant with prior studies on tobacco use among adolescents with behavioral problems. Although the magnitude of observed associations varied according to the country of residence, the strength of these associations and their significance by conventional standards were observed in nearly all the countries sampled. This is the first study in these seven countries on potentially causal relationships such as these. More research is needed to augment our knowledge regarding the observed cross-country differences and ultimately to develop, implement, and evaluate effective tobacco preventative intervention programs (AU)

Dolor abdominal recurrente: un trastorno somatomorfo / Recurrent abdominal pain: a somatomorf disorder

El dolor abdominal recurrente es un problema común en pediatría. La etiología es desconocida, aunque se relaciona con un origen psicosomático. En este trabajo analizamos el dolor abdominal recurrente como trastorno somatomorfo indiferenciado, según los criterios del DSM-IV, y estudiamos los factores psicológicos asociados a la etiología, fisiopatología, diagnóstico y tratamiento (AU)

Expressed emotion and relapse.

The relatives of 82 patients in a study of first episodes of schizophrenia were interviewed within six weeks of the index admission; 77 patients were subsequently discharged, and were followed to relapse or readmission. Analysis of relapse-free survival time was used to examine whether the components of 'expressed emotion' predicted relapse or response to neuroleptic medication: 'critical comments' by relatives was the only component present often enough to be used and was inversely related to 'social contact'. When preadmission duration of illness, and neuroleptic medication following discharge (identified previously as significant predictors of outcome) were taken into account, neither 'critical comments' nor 'social contact' were related to outcome nor to response to medication. The constellation of factors suggested as pathogenic was present only in a minority of cases: many patients lived alone and of those that were with families, most were not in high face-to-face contact with other members. The failure of the components of 'expressed emotion' to predict outcome or response to neuroleptic medication suggests that at best, such factors are weak predictors of liability to relapse. Their influence is unlikely to be comparable in magnitude to that of neuroleptic medication.