[Augmented psychotherapy with rTMS in functional neurological disorder]. / Psychothérapie augmentée par rTMS pour les troubles neurologiques fonctionnels.

BACKGROUND: We report the observation of a 47-year-old woman with functional neurological disorder (tetraparesis, mixed tremors and non-epileptic seizures) treated with a protocol of augmented psychotherapy in combination with repeated transcranial magnetic stimulation (rTMS). INTERVENTION: We carried out a biofeedback psychotherapy protocol with rTMS (twenty sessions, two sessions per day for ten days; 1Hz, 150% of the motor threshold, twenty minute sessions, 300 pulses per session) in which the patient visualized the motor activity of her upper limbs during stimulation of the primary motor area (PMA). The evolution of neurological symptoms was assessed using the Medical Research Council Scale for Muscle Strength (MRC). RESULTS: Symptoms were improved between the 4th and 6th days of treatment (8th and 12th sessions) with first a relief of paresis, then a secondary cascade improvement of other functional symptoms. At two months the patient no longer presented any functional neurological symptoms. DISCUSSION & CONCLUSION: We propose several hypotheses concerning the effectiveness of this type of biofeedback protocol using rTMS. We also suggest that this type of protocol should be systematically associated with psychotherapeutic support on biographical elements for holistic management. This observation underlines the interest of potentiating cognitive-behavioral therapies using the principle of operant conditioning with the aid of brain stimulation in functional neurological disorders, and motivates the realization of future studies.

Characterizing neuropsychiatric symptoms in subjects referred to dementia clinics.

OBJECTIVE: To characterize the neuropsychiatric symptoms (NPS) of subjects classified as not cognitively impaired (NCI), cognitively impaired-not demented (CIND), and dementia. METHODS: A Canadian Cohort Study of Cognitive Impairment and Related Dementias (ACCORD) is a longitudinal investigation of individuals referred to eight Canadian dementia centers for evaluation of cognitive impairment and neurobehavioral symptoms. Of the inception cohort of 804 subjects for whom the informant-based Neuropsychiatric Inventory (NPI) was completed at study entry, 35 were classified as NCI, 193 as CIND, and 576 as dementia. The three diagnostic groups were compared on each of the 12 NPI items. Within each diagnostic group, comparisons were also made between symptomatic (NPS+; total score > 1) and asymptomatic (NPS-; total score = 0) subjects on measures of general cognitive status and functional disability. A subset of the NCI and CIND individuals were also compared on a comprehensive neuropsychological test battery. RESULTS: There was at least one NPI item reported in 60% of subjects with NCI, 74% with CIND, and 89% with dementia. The item scores for delusions, hallucinations, agitation, apathy, disinhibition, aberrant motor behavior, and problems with appetite were greater in dementia subjects than in NCI or CIND. There were no significant differences between subjects with NCI and CIND on any NPI item. For each diagnostic group, NPS+ subjects were more impaired on functional but not neuropsychological measures. CONCLUSIONS: Across all levels of cognition, neuropsychiatric symptoms (NPS) are an important feature in individuals referred to dementia clinics. The current data suggest that NPS may precede cognitive deficits in individuals classified as not cognitively impaired and cognitively impaired-not demented.

Predictors of seizure outcome following cortical resection in pediatric and adolescent patients with medically refractory epilepsy.

Several preoperative clinical variables have been reported to have value as predictors of seizure outcome following the surgical resection of epileptogenic focus in adults who have had medically refractory epilepsy. The present paper reports the results of a retrospective review of the ability of these variables to predict seizure outcome in a group of pediatric patients who had medically refractory epilepsy and underwent surgical resection of an epileptogenic focus at the Children's Hospital of Eastern Ontario. Variables in this review included age at first seizure, age at time of surgery, duration of seizures, seizure type, sex, family history, etiology, level of intelligence, EEG data, results of imaging studies, findings on examination of the central nervous system, and location and site of surgical resection. We found 64 patients who met the entry criteria for this review. Normal intelligence and tumor as etiology were associated with a good postoperative seizure outcome in patients who had a temporal resection; no variables had positive correlation with outcome in the extratemporal group. Caution must be used in the extrapolation of data and inclusion of studies of predictors of seizure outcome for adults to pediatric age groups.

Long-term socioeconomic outcome following surgical intervention in the treatment of refractory epilepsy in childhood and adolescence.

Surgical treatment of refractory epilepsy in childhood and adolescence has been shown to be effective in reducing the seizure frequency. This paper examines the question: "Does this result in a better socioeconomic outcome in later years?" Patients who underwent a surgical procedure for the treatment of their medically refractory epilepsy at our hospital, had more than 2-years' follow-up, and were less than 18 years old at time of survey were included. From a retrospective chart review, age at onset and at surgery, duration of seizures prior to surgery, years of follow-up, type of surgery, and neurological status were obtained. From a telephone survey, seizure frequency after surgery, marital, financial and driving status, level of education, and employment status were ascertained. Sixty-four patients in our epileptic surgical series meet entry criteria. Significantly higher levels of education, employment status and independence were found in patients with a class I Engel outcome compared to other Engel outcomes.

Patient satisfaction with surgical treatment of refractory epilepsy done in childhood and early adolescence.

The results of a retrospective self-controlled telephone satisfaction survey of 63 patients who had undergone an earlier resection for the treatment of medically refractory epilepsy before the age of 18 years was reported. The survey items consisted of a global rating scale and a series of open-ended questions about positive and negative outcomes as a result of the surgery. Most (80%) of the patients felt the surgery had had a positive effect on their lives. The mean global score was 6.24+2.4 (scale 0-9). Strong positive correlations were found between seizure control and degree of satisfaction and between perceived postsurgical neurological deficits and dissatisfaction.

Nursing as a research-based profession: 22 years after Briggs.

This review examines the growth of nursing research in the UK over the past 22 years and questions nursing's claim to be a research-based profession, as the consensus of opinion is that research findings have generally failed to influence clinical practice.

Recovery nursing: oxygen mask or nasal catheter? An analysis.

In pursuit of cost-efficiency without compromising standards of patient care, a study was undertaken to compare the performances of a medium concentration facemask and a nasal catheter, by measuring the oxygen saturation levels of 40 post-operative patients. Statistical analysis revealed that when oxygen is delivered at 3 litres/minutes, there is no significant difference between the performances of these systems. Patients and nurses indicated a preference for the nasal catheter compared with the facemask. These findings are consistent with previous work in this area, and the wider use of the nasal catheter is called for in oxygen administration to selected post-operative patients.

Intuition as a function of the expert nurse: a critique of Benner's novice to expert model.

Benner's model of skill acquisition is currently receiving considerable interest from nurse educationalists, and promises to form the basis for some curricula offered by colleagues of nurse education. This paper debates the 'novice to expert' model and seeks to explain exactly what an 'expert' is. The Benner model proposes that one component of expertise is working from an intuitive base. This claim is disputed and the definition of intuition is contested. Alternative explanations to account for the intuitive responses of Benner's subjects are suggested.