The Integrated Care Team Approach of the Department of Veterans Affairs (VA): Geriatric Primary Care.

Historically, integrated mental and behavioral healthcare in the Department of Veterans Affairs (VA) commenced with initiatives in geriatrics. Innovation and system-wide expansion has occurred over decades and culminated in a unified vision for training and practice in the VA medical home model: Patient Aligned Care Team or PACT approach. In one VA hospital, the integration of neuropsychological services in geriatric primary care is pivotal and increases access for patients, as well as contributing to timely and effective care on an interprofessional team. The development and innovative use of an algorithm to identify problems with cognition, health literacy, and mental and behavioral health has been pragmatic and provides useful information for collaborative treatment planning in GeriPACT, VA geriatric primary care. Use of the algorithm also assists with decision-making regarding brief versus comprehensive neuropsychological assessment in the primary care setting. The model presented here was developed by supervising neuropsychologists as part of a postdoctoral residency program in geropsychology. However, postdoctoral residency programs in neuropsychology, as well as neuropsychological clinics, can also use this model to integrate neuropsychological assessment and interventions in geriatric primary care settings.

The Evolution of Psychology as a Basic Bio-behavioral Science in Healthcare Education.

For over a century, researchers and educators have called for the integration of psychological science into medical school curricula, but such efforts have been impeded by barriers within medicine and psychology. In addressing these barriers, Psychology has re-examined its relationship to Medicine, incorporated psychological practices into health care, and redefined its parameters as a science. In response to interdisciplinary research into the mechanisms of bio-behavioral interaction, Psychology evolved from an ancillary social science to a bio-behavioral science that is fundamental to medicine and health care. However, in recent medical school curriculum innovations, psychological science is being reduced to a set of "clinical skills," and once again viewed as an ancillary social science. These developments warrant concern and consideration of new approaches to integrating psychological science in medical education.

Potential implications of Luria's work for the neuropsychology of epilepsy and epilepsy surgery: A perspective for re-examination.

The pioneeristic work of Alexander Romanovic Luria into the field of human neuropsychology offered eminent contributions to clinical praxis by providing theory guided methods and instruments for the study of higher cortical functions. However, lots of this knowledge corpus either remains untranslated and thus inaccessible, or in some cases selectively overlooked by academic authorities and consequently not passed to the future generations of experts. Although Luria was not exclusively devoted to the study of epilepsy, his theories and clinical approaches actually penetrate the whole neuropathology spectrum. His holistic and systemic approach to the brain sounds nowadays more than opportune and consistent with the network approach of the modern neuroimaging era. As to epilepsy, the logic underlying the Lurian approach (cognitive functions organized into complex functional systems with intra- and/or inter-hemispheric distribution, as opposed to the modularistic view of the brain) seems consistent with our current knowledge in epileptology with respect to epileptic networks, as well as the modern construct of the functional deficit zone. These contributions seem to be highly promising for the neuropsychology of epilepsy and epilepsy surgery, since they provide clinicians with valuable methods and theories to assist them in the localization -and lateralization- of cognitive deficits. Consequently they are of great applicability in the context of the preoperative neuropsychological monitoring of patients candidates for epilepsy surgery, where neuropsychologist are called upon to provide surgeons with anatomical data.

Efectos de los inductores antiepilépticos en la neuropsicofarmacología: una cuestión ignorada. Parte II: cuestiones farmacológicas y comprensión adicional / The effects of antiepileptic inducers in neuropsychopharmacology, a neglected issue. Part II: pharmacological issues and further understanding

La literatura sobre los inductores en la epilepsia y el trastorno bipolar está contaminada por falsos negativos. Esta segunda parte de una revisión exhaustiva sobre los fármacos antiepilépticos (FAE) con propiedades inductoras aporta más material educativo a los clínicos acerca de la complejidad de interpretar sus interacciones farmacológicas. Se revisa la farmacología básica de la inducción incluyendo los citocromos P450 (CYP), las enzimas de glucuronización (UGT) y la glucoproteína P (P-gp). Los CYP2B6 y CYP3A4 son muy sensibles a la inducción. El CYP1A2 es moderadamente sensible. Los el CYP2C9 y el CYP2C19 son solo levemente sensibles. El CYP2D6 no puede ser inducida por los fármacos. La inducción de las enzimas metabólicas, los CYP o las UGT, y los transportadores como la P-gp, se debe a un incremento de la síntesis de estas proteínas mediado por los denominados receptores nucleares (receptores constitutivo de androstano, de los estrógenos, de los glucocorticoides y de pregnano X). Aunque la primera parte de este artículo describe los factores de corrección para los antiepilépticos inductores, la extrapolación de estos valores desde un paciente promedio a un individuo concreto está influenciada por la ruta de administración, la carencia de la enzima metabólica debida a razones genéticas, y la presencia de inhibidores, u otros inductores. También pueden ser importantes las interacciones farmacológicas de los FAE al nivel de los mecanismos farmacodinámicos. Se describen 6 pacientes con una sensibilidad extrema a los inductores antiepilépticos (AU)

The literature on inducers in epilepsy and bipolar disorder is seriously contaminated by false negative findings. Part II of this comprehensive review on antiepileptic drug (AED) inducers provides clinicians with further educational material about the complexity of interpreting AED drug-drug interactions. The basic pharmacology of induction is reviewed including the cytochrome P450 (CYP) isoenzymes, the Uridine Diphosphate Glucuronosyltransferases (UGTs), and P-glycoprotein (P-gp). CYP2B6 and CYP3A4 are very sensitive to induction. CYP1A2 is moderately sensitive while CYP2C9 and CYP2C19 are only mildly sensitive. CYP2D6 cannot be induced by medications. Induction of UGT and P-gp are poorly understood. The induction of metabolic enzymes such as CYPs and UGTs, and transporters such as P-gp, implies that the amount of these proteins increases when they are induced; this is almost always explained by increasing synthesis mediated by the so-called nuclear receptors (constitutive androstane, estrogen, glucocorticoid receptors and pregnane X receptors). Although part i provides correction factors for AEDs, extrapolation from an average to an individual patient may be influenced by administration route, absence of metabolic enzyme for genetic reasons, and presence of inhibitors or other inducers. AED pharmacodynamic DDIs may also be important. Six patients with extreme sensitivity to AED inductive effects are described (AU)

Atención interdisciplinar del daño cerebral / Interdisciplinary attention of the head injury

El daño cerebral constituye una de las principales causas de discapacidad en nuestra sociedad actual y puede comportar cambios físicos, cognitivos, emocionales y del comportamiento que deben abordarse desde distintas disciplinas, por lo que la atención interdisciplinar es fundamental en todo el proceso de rehabilitación. Además, las secuelas derivadas del daño cerebral conllevan problemas de dependencia que afectarán tanto al propio paciente, como a sus familiares, los cuales deberán asumir el rol de cuidadores principales, con las consiguientes repercusiones en su calidad de vida. Los diferentes profesionales implicados en el proceso de recuperación, deberán atender a las personas afectadas desde una perspectiva interdisciplinar en base a su especialización, favoreciendo una atención integral de los pacientes afectados y de sus familias. Tanto la valoración logopédica como la neuropsicológica, deben realizarse desde la fase aguda y también a lo largo de todo el proceso de rehabilitación. A su vez, logopedas y neuropsicólogos deberán trabajar de forma coordinada y también conjuntamente con todos los profesionales del equipo de rehabilitación, puesto que los trastornos del lenguaje y de la comunicación, así como los déficit cognitivos, emocionales y del comportamiento afectan muy directamente al funcionamiento del paciente y a su relación con la familia y el entorno. En la actualidad, los programas de rehabilitación del daño cerebral deben plantearse desde una aproximación holística, según la cual el tratamiento se realiza desde una perspectiva global, incluyendo también a la familia en todo el proceso de recuperación y fomentando, a su vez, la readaptación profesional y social del paciente, siendo por tanto fundamental el trabajo interdisciplinar (AU)

Head injury constitutes one of the main causes of disability in our society and produces physical, cognitive, emotional and behavioral changes, that have to be assisted from different disciplines and interdisciplinary attention is very important in all of the rehabilitation process. Moreover, squeals derived from head injury produce dependence problems that will affect patients and their relatives, who will have to take care of them and this would affect their quality of live. Professionals that take part in the rehabilitation process have to work from an interdisciplinary perspective according to their specialty, with an integrated attention to patients and relatives. Both, speech and language assessment and neuropsychological assessment have to be made since the acute phase and during all the rehabilitation process. Moreover, speech and language therapists and neuropsychologists have to work in a coordinated way and together with all professionals of the rehabilitation team, as language and communicative disorders, and cognitive, emotional and behavioral changes affect directly patients functioning and their relationship with relatives. Nowadays, head injury rehabilitation programs are based on the holistic approach, in which patients receive treatment from a global perspective, including their relatives in all the recovery process, and helping patients in their professional and social outcome, working from an interdisciplinary way (AU)

Uso racional del yoduro potásico durante el embarazo y la lactancia / Rational use of potassium iodine during pregnancy and lactation

La deficiencia de yodo grave y moderada durante la gestación y la lactancia afecta a la función tiroidea de la madre y del neonato, así como al desarrollo neuropsicológico del niño. En la mayoría de los países de Europa el estado nutricional de yodo de gestantes y recién nacidos es deficiente, pues las necesidades de yodo en las mujeres embarazadas y en las que amamantan a sus hijos son al menos el doble de las recomendadas para la población adulta. Estudios realizados en España confirman que la mayoría de las mujeres se encuentran en yododeficiencia durante la gestación y la lactancia y muestran quela ingesta de sal yodada no es suficiente para conseguir un estado nutricional de yodo óptimo en esta población. Varios estudios demuestran el efecto beneficioso de la suplementación de yodo de las embarazadas sobre el estado nutricional de yodo y la función tiroidea de la madre y el recién nacido. Las mujeres embarazadas, las que amamantan a sus hijos y las que planifican su gestación deberían recibir suplementos de yodo en forma de tabletas de yoduro potásico (AU)

Severe and mild iodine deficiency during pregnancy and lactation affects thyroid function of the mother and neonate as well as the infant’s neuropsychological development. In most European countries, maternal and neonatal iodine status is deficient, since iodine requirements in pregnant and lactating women are almost double those recommended for non pregnantor non-lactating women. Studies performed in Spain confirm that most women are iodine deficient during pregnancy and lactation, and show that iodized salt intake is insufficient to achieve optimal iodine nutritional status in this population. Several studies have demonstrated the beneficial effect of iodine supplementation in pregnant women on the iodine and thyroid status of both mother and neonate. Pregnant and breastfeeding women and women planning to become pregnant should take iodine supplements in the form of potassium iodide tablets (AU)

Cajal y la psiquiatría biológica: actividades profesionales y trabajos científicos de Cajal en el campo de la psiquiatría / Cajal and biological psychiatry: professional activities and scientific works of Cajal in the psychiatry field

Santiago Ramón y Cajal dedicó parte de su actividad científica al estudio experimental de aspectos relacionados con la psiquiatría. El primer contacto de Cajal con estos temas tuvo lugar a través del estudio experimental del hipnotismo. Siguiendo la concepción psicoterápica de Bernkein. Cajal interpretó el fenómeno de la sugestión hipnótica como un fallo aberrante de la maquinaria cerebral. Posiblemente, el interés inicial de Cajal por la sugestión hipnótica dio paso, con los años, al estudio de los fenómenos biológicos relacionados con el sueño y el ensueño, en cuya explicación neurofisiológica discrepaba abiertamente con los postulados de Freud. Cajal se ocupó también del estudio de los mecanismos histofisiológicos de los procesos psíquicos superiores (pensamiento, inteligencia, memoria, percepción, etc.), según las corrientes científicas de la época, muy proclives a este tipo de interpretaciones. Cajal puso a las células piramidales de la corteza cerebral, a las que denominó “células psíquicas”, como las candidatas para asentar el sustrato de estas funciones psicológicas superiores, asignó algún papel a las células neurológicas de la sustancia gris, planteó, siguiendo las corrientes psicológicas del asociacionismo, su ley del “alud nervioso”, y especuló con la posibilidad de un fenómeno de plasticidad neuronal en relación con los procesos del aprendizaje. Finalmente, dedicó algunas publicaciones a la descripción de las alteraciones histopatológicas de los cerebros de pacientes esquizofrénicos. Desde el punto de vista clínico y anecdótico, Cajal fundó un Comité de Investigaciones Psicológicas en su época valenciana, en el que ejerció la terapéutica sofrológica, y abrió, durante algunos meses, una consulta de Neuropatología y Psiquiatría en su periodo madrileño

Santiago Ramón y Cajal dedicated part of his scientific work to the experimentl study of aspects related to psychiatry. Cajal´s first contact with these subjects took place through experimental study of hypnotism. Following the psychotherapeutical approach of Bernheim. Cajal interpreted the phenomenon of hypnotic suggestion as an aberrant failure of the cerebral machinery. Possibly, Cajalñs initial interest in hypnotic suggestion gave way over the years to the study of the biological phenomena related to sleep and dreams, in whose neurophysiological explanation he differed apenly with the postulates of Freud. Cajal also studied the histophysiological mechanisms of the higher mental functions (thought, intelligence, memory, perception, etc.), on which the scientific thinking of the tima was greatly inclined to this type of interpretation. Cajal proposed the pyramidal cells of the cerebral cortex, which he called “physic cells”, as the possible seat of the substrate of these superior psychological functions. He assigned certain roles to the neuroglial cells of grey matter. In accordance with the psychological trend of association, he proposed his “law of avalanche conduction”. He speculated on the possibility of a phenomenon of neuron plasticity in relation to the learning processes. Finally, he dedicated some publications to the description of the histopathological alterations of the brains of schizophrenia patients. From the clinical and anecdotal point of view. Cajal founded a Committee of Psychological Research during his time in Valencia, when he practiced relaxation therapy, and for a few months during his time in Madrid, he opened a Neuropathology practice

Vagus nerve stimulation for the treatment of depression and other neuropsychiatric disorders.

Vagus nerve stimulation is an interesting new approach to treating neuropsychiatric diseases within the class of brain-stimulation devices sometimes labeled 'neuromodulators'. With vagus nerve stimulation, a battery-powered generator implanted in the chest wall connects to a wire wrapped around the vagus nerve in the neck, and sends intermittent pulses of electricity along the nerve directly into the brain. This mechanism takes advantage of the natural role of the vagus nerve in conveying information into the brain concerning homeostatic information (e.g., hunger, chest pain and respirations). Vagus nerve stimulation therapy is US FDA approved for the adjunctive treatment of epilepsy and has recently been FDA approved for the treatment of medication-resistant depression. Owing to its novel route into the brain, it has no drug-drug interactions or systemic side effects. This treatment also appears to have high long-term tolerability in patients, with low rates of patients relapsing on vagus nerve stimulation or becoming tolerant. However, alongside the excitement and enthusiasm for this new treatment, a lack of Class I evidence of efficacy in treating depression is currently slowing down adoption by psychiatrists. Much more research is needed regarding exactly how to refine and deliver the electrical pulses and how this differentially affects brain function in health and disease.

Psiconeuroimunologia: a superaçäo do dualismo cartesiano / Psychoneuroimmunology: outdoing the cartesian dualism

No estudo da História da Filosofia a interaçäo dos princípios corpo-alma e soma-psique vêm preocupando o homem desde Anaxágoras, passando por Aristóteles, Platäo, Leibnitz, Spinoza para desaguar no "dualismo psicofísico interacionista" de Descartes. O pensamento psicossomático representou, inicialmente, mas sem sucesso, uma tentativa de superaçäo da dicotomia cartesiana, tendo em vista uma visäo integral do homem. A seguir o autor discorre sobre as formulaçöes filosóficas de Zubiri, para elaborar o seu conceito de Homem total. Ao homem näo se pode concebê-lo senäo como imerso em seu mundo. Essa é a razäo pela qual a filosofia existencial, e mais concretamente a de Heidegger, considera o homem como um ser "lançado no mundo". O autor discorre, finalmente, a respeito das relaçöes da filosofia de Zubiri, a qual leva o homem, inevitavelmente, à presença da Divindade