bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluating biomarkers for treatment selection from reproducibility studies
Authors: Song Xiao , Dobbin Kevin K
Published: March 2020

We consider evaluating new or more accurately measured predictive biomarkers for treatment selection based on a previous clinical trial involving standard biomarkers. Instead of rerunning the clinical trial with the new biomarkers, we propose a more efficient approach which requires only either conducting a reproducibility study in which the new biomarkers and standard biomarkers are both measured on a set of patient samples, or adopting replicated measures of the error-contaminated standard biomarkers in the original study. This approach is easier to conduct and much less expensive than studies that require new samples from patients randomized to the intervention. In addition, it makes it possible to perform the estimation of the clinical performance quickly, since there will be no requirement to wait for events to occur as would be the case with prospective validation. The treatment selection is assessed via a working model, but the proposed estimator of the mean restricted lifetime is valid even if the working model is misspecified. The proposed approach is assessed through simulation studies and applied to a cancer study.
Borrowing of information across patient subgroups in a basket trial based on distributional discrepancy
Authors: Zheng Haiyan , Wason James M S
Published: March 2020

Basket trials have emerged as a new class of efficient approaches in oncology to evaluate a new treatment in several patient subgroups simultaneously. In this article, we extend the key ideas to disease areas outside of oncology, developing a robust Bayesian methodology for randomized, placebo-controlled basket trials with a continuous endpoint to enable borrowing of information across subtrials with similar treatment effects. After adjusting for covariates, information from a complementary subtrial can be represented into a commensurate prior for the parameter that underpins the subtrial under consideration. We propose using distributional discrepancy to characterize the commensurability between subtrials for appropriate borrowing of information through a spike-and-slab prior, which is placed on the prior precision factor. When the basket trial has at least three subtrials, commensurate priors for point-to-point borrowing are combined into a marginal predictive prior, according to the weights transformed from the pairwise discrepancy measures. In this way, only information from subtrial(s) with the most commensurate treatment effect is leveraged. The marginal predictive prior is updated to a robust posterior by the contemporary subtrial data to inform decision making. Operating characteristics of the proposed methodology are evaluated through simulations motivated by a real basket trial in chronic diseases. The proposed methodology has advantages compared to other selected Bayesian analysis models, for (i) identifying the most commensurate source of information and (ii) gauging the degree of borrowing from specific subtrials. Numerical results also suggest that our methodology can improve the precision of estimates and, potentially, the statistical power for hypothesis testing.
Elucidating neural network changes induced by deep brain stimulation for OCD
Authors: Kuhn Jens , Baldermann Juan Carlos
Published: March 2020

This scientific commentary refers to ‘Deep brain stimulation modulates directional limbic connectivity in obsessive-compulsive disorder’, by Fridgeirsson etal. (doi:10.1093/brain/awaa100).
Heritable arrhythmias associated with abnormal function of cardiac potassium channels
Authors: Crotti Lia , Odening Katja E , Sanguinetti Michael C
Published: March 2020

Cardiomyocytes express a surprisingly large number of potassium channel types. The primary physiological functions of the currents conducted by these channels are to maintain the resting membrane potential and mediate action potential repolarization under basal conditions and in response to changes in the concentrations of intracellular sodium, calcium, and ATP/ADP. Here, we review the diversity and functional roles of cardiac potassium channels under normal conditions and how heritable mutations in the genes encoding these channels can lead to distinct arrhythmias. We briefly review atrial fibrillation and J-wave syndromes. For long and short QT syndromes, we describe their genetic basis, clinical manifestation, risk stratification, traditional and novel therapeutic approaches, as well as insights into disease mechanisms provided by animal and cellular models.
Migrating Extremists
Authors: Ochsner Christian , Roesel Felix
Published: March 2020

We show that migrating extremists can shape political equilibria in the long run. Regions in Austria that witnessed an influx of Nazis fleeing the Soviets after WWII still have significantly higher far-right vote shares today. Institutions and family ties perpetuate persistence. Migrated Nazi elites founded and penetrated local party branches that cultivate and preserve far-right ideologies, even when outside conditions temporarily change. Phonebook entries from 1942 allow tracing current far-right party membership back to past migration. Our results suggest that controlling migrating extremists is crucial to contain the spread of radical movements.
A parallel side graft—frontage graft—technique for intercostal artery reimplantation during thoraco-abdominal aorta replacement
Authors: Lee Jae Hang , Park Kay-Hyun
Published: March 2020

In the conventional way of thoraco-abdominal aortic replacement, the intercostal arteries are reimplanted directly to the main aortic graft or by the interposition of branch grafts. To overcome the disadvantages of these techniques, we adopted a different technique using a parallel side graft. The good patency rate of reimplanted intercostal arteries achieved by this technique and its potential technical advantages can contribute to the improvement of the surgical outcome.
Youth injury and parents’ unemployment—the importance of socio-economic status and ethnicity context
Authors: Maya Siman-Tov , Aviad Tur-Sinai , Tanya Kolobov , Orna Baron-Epel , Yossi Harel-Fisch
Published: March 2020

Background

Youth whose parents are unemployed have poorer health and well-being, including more injuries that result in hospitalization. The current study examined the possibility of an association of parents’ employment status with youth injury and the interaction of this status with other socio-economic factors and ethnicity.

Methods

We distributed to adolescents aged 11–15 years, in class, the Israel Health Behavior in School-Aged Children Survey. We distinguished between any injury and severe injury, defining the latter as one necessitating the use of a cast, stitches and crutches or overnight hospitalization.

Results

Of 13 705 respondents, 6224 (45%) had an injury in the past year that required medical treatment and 1827 pupils (13.5%) reported severe injuries. The odds of any injury were 1.86 for boys as against girls (95% confidence interval [CI] 1.73–1.99), 0.80 for school grade (95% CI 0.78–0.82), 1.56 for Arabs vs. Jews (95% CI 1.43–1.70) and 1.10 for high Family Affluence Scale (FAS) vs. medium FAS (95% CI 1.01–1.21). Only in the low FAS group, when two parents were unemployed, the odds for severe injury was 1.36 (95% CI 1.03–1.78); when one or two parents were employed, the odds of severe child injury were the same (OR 1.13 and 95% CI 0.92–1.40).

Conclusion

Factors that were found to increase the risk of injury among youth were parental unemployment, low socio-economic status and Arab ethnicity. The home environment was the most common place for injury.
HIV prevention and treatment in Southern Europe in the aftermath of bailout programmes
Authors: Augusto Gonçalo F , Hodges-Mameletzis Ioannis , Karanikolos Marina , Abrantes Alexandre , Martins Maria R O
Published: March 2020

Background

The global financial crisis impacted public health in Europe, and had a particularly critical detriment to health systems in Southern Europe. We aim to describe HIV response and progress towards the current global HIV targets in specific Southern European countries, which received financial adjustment programmes.

Methods

We examined and compared a set of HIV indicators in Cyprus, Greece, Portugal and Spain. The indicators included: (i) HIV epidemiology; (ii) adoption of WHO’s ‘Treat All’ recommendation; (iii) progress towards the UNAIDS global targets of 90–90–90; (iv) adoption/implementation of pre-exposure prophylaxis (PrEP); and (v) adoption/implementation of WHO’s HIV self-testing (HIVST) recommendation.

Results

HIV incidence varied across countries since 2010, with sustained declines in Portugal and Spain, and marked increases in Greece and Cyprus. By 2016, all four countries have adopted WHO’s ‘Treat All’ recommendation, leading to a marked increase in people receiving ART. Improvements were seen in all 90–90–90 targets, with Portugal achieving those in 2017, but Greece lagging somewhat behind, as of 2016. Portugal and Spain have also started implementing PrEP, and Greece has completed a pilot with no additional access to PrEP for pilot participants and no national programme in place. Cyprus has been the slowest in terms of adopting PrEP and HIVST.

Conclusions

Countries need to focus on prioritizing effective and comprehensive prevention measures, including HIVST and PrEP, and scale-up access to quality treatment and care for those diagnosed, in order to accelerate the reduction of new HIVs infections and successfully meet the global targets for HIV treatment.
An Outreach Rehabilitation Program for Nursing Home Residents After Hip Fracture May Be Cost-Saving
Authors: Beaupre Lauren A , Lier Doug , Magaziner Jay S , Jones C Allyson , Johnston D William C , Wilson Donna M , Majumdar Sumit R
Published: March 2020

Background

We compared the cost-effectiveness of 10 weeks of outreach rehabilitation (intervention) versus usual care (control) for ambulatory nursing home residents after hip fracture.

Methods

Enrollment occurred February 2011 through June 2015 in a Canadian metropolitan region. Seventy-seven participants were allocated in a 2:1 ratio to receive a 10-week rehabilitation program (intervention) or usual care (control) (46 intervention; 31 control). Using a payer perspective, we performed main and sensitivity analyses. Health outcome was measured by quality-adjusted life years (QALYs), using the EQ5D, completed at study entry, 3-, 6-, and 12-months. We obtained patient-specific data for outpatient visits, physician claims, and inpatient readmissions; the trial provided rehabilitation utilization/cost data. We estimated incremental cost and incremental effectiveness.

Results

Groups were similar at study entry; the mean age was 87.9 ± 6.6 years, 54 (71%) were female and 58 (75%) had severe cognitive impairment. EQ5D QALYs scores were nonsignificantly higher for intervention participants. Inpatient readmissions were two times higher among controls, with a cost difference of −$3,350/patient for intervention participants, offsetting the cost/intervention participant of $2,300 for the outreach rehabilitation. The adjusted incremental QALYs/patient difference was 0.024 favoring the intervention, with an incremental cost/patient of −$621 for intervention participants; these values were not statistically significant. A sensitivity analysis reinforced these findings, suggesting that the intervention was likely dominant.

Conclusion

A 10-week outreach rehabilitation intervention for nursing home residents who sustain a hip fracture may be cost-saving, through reduced postfracture hospital readmissions. These results support further work to evaluate postfracture rehabilitation for nursing home residents.
Pulled or pushed? The spatial diffusion of wind energy between local demand and supply
Authors: Bednarz Marcel , Broekel Tom
Published: March 2020

This article contributes to and connects the literature on spatial innovation diffusion, entrepreneurship, and industry life-cycles by disentangling the relevance of local demand and supply in the adoption of wind energy production. More precisely, we evaluate the strength of local supply–push effects with those of local demand–pull over the course of the evolution of an industry and its main product evolution. By using Bayesian survival models with time-dependent data of wind turbine deployment and firm foundation for 402 German regions between the years 1970 and 2015, we show that the spatial evolution of the German wind energy industry was more strongly influenced by local demand–pull than local supply–push processes. New producers are found to emerge in proximity to existing local demand for wind turbines. No evidence was found for producers being able to create local demand for their products by pushing the adoption of the technology in their regions.
Temporal pattern of aortic remodelling after endovascular treatment for chronic DeBakey IIIb dissection
Authors: Kim Tae-Hoon , Song Suk-Won , Heo Woon , Lee Kwang-Hun , Yoo Kyung-Jong , Lee Hye Sun , Cho Bum-Koo
Published: March 2020

OBJECTIVES

Endovascular treatment has emerged as a safe procedure for treating chronic DeBakey IIIb dissection. The objective of this study was to investigate the mid-term outcome and temporal pattern of aortic remodelling after endovascular treatment for DeBakey IIIb dissection.

METHODS

From 2012 to 2017, 85 patients who underwent endovascular aortic repair for DeBakey IIIb dissection were enrolled. The temporal pattern of aortic remodelling in terms of false lumen (FL) thrombosis [level 1 (∼T7), level 2 (T7 ∼ coeliac axis) and level 3 (coeliac trunk ∼ aortic bifurcation)] and aortic diameter [mid-thoracic level (T7), coeliac axis and the largest infrarenal abdominal aorta] was investigated on serial follow-up computed tomography scan.

RESULTS

Eighty-five patients underwent endovascular treatment during the study period. Male sex was a significant risk factor for repetitive reintervention and segments 2 and 3 FL thrombosis. The preoperative FL diameter at T7 was significantly associated with FL diameter regression. The number of visceral vessels from the FL and residual DeBakey IIIb dissection after type A repair were significant factors for FL growth at the coeliac trunk and at the largest infrarenal abdominal aorta. The overall mortality was 3 (3.6%).

CONCLUSIONS

Endovascular treatment is a safe strategy in the management of DeBakey IIIb dissection. However, unfavourable aortic remodelling and repetitive reintervention were expected in male patients with a large number of visceral vessels from the FL and residual DeBakey IIIb dissection after type A repair. Endovascular treatment should be cautiously considered, and close follow-up is required for these patients.
Dicamba use and cancer incidence in the agricultural health study: an updated analysis
Authors: Lerro Catherine C , Hofmann Jonathan N , Andreotti Gabriella , Koutros Stella , Parks Christine G , Blair Aaron , Albert Paul S , Lubin Jay H , Sandler Dale P , Beane Freeman Laura E
Published: March 2020

Background

The herbicide dicamba has been commonly used agriculturally and residentially. Recent approval of genetically engineered dicamba-resistant crops is expected to lead to increased dicamba use, and there has been growing interest in potential human health effects. A prior analysis in the Agricultural Health Study (AHS) suggested associations between dicamba and colon and lung cancer. We re-evaluated dicamba use in the AHS, including an additional 12 years and 2702 exposed cancers.

Methods

The AHS is a prospective cohort of pesticide applicators in Iowa and North Carolina. At enrollment (1993–1997) and follow-up (1999–2005), participants reported dicamba use. Exposure was characterized by cumulative intensity-weighted lifetime days, including exposure lags of up to 20 years. We estimated relative risks (RR) and 95% confidence intervals (CI) using multivariable Poisson regression for incident cancers diagnosed from enrollment through 2014/2015.

Results

Among 49 922 applicators, 26 412 (52.9%) used dicamba. Compared with applicators reporting no dicamba use, those in the highest quartile of exposure had elevated risk of liver and intrahepatic bile duct cancer (nexposed = 28, RRQ4 = 1.80, CI: 1.26–2.56, Ptrend < 0.001) and chronic lymphocytic leukaemia (CLL, nexposed = 93, RRQ4 = 1.20, CI: 0.96–1.50, Ptrend = 0.01) and decreased risk of myeloid leukaemia (nexposed = 55, RRQ4 = 0.73, CI: 0.51–1.03, Ptrend = 0.01). The associations for liver cancer and myeloid leukaemia remained after lagging exposure of up to 20 years.

Conclusions

With additional follow-up and exposure information, associations with lung and colon cancer were no longer apparent. In this first evaluation of liver and intrahepatic bile duct cancer, there was an association with increasing use of dicamba that persisted across lags of up to 20 years.
Psychosocial Factors and the Care Cascade for Hepatitis C Treatment Colocated at a Syringe Service Program
Authors: Winetsky Daniel , Burack Daniel , Antoniou Pantelis , Garcia Bill , Gordon Peter , Scherer Matthew
Published: March 2020

Background

Direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) is highly effective. However, people who inject drugs face significant barriers to DAA access.

Methods

We describe a program that colocates HCV management within a syringe service program in New York City. We performed a retrospective chart review of all patients with confirmed HCV viremia.

Results

From 2015 to 2018, 102 patients with viremia completed intake. Fifty-eight patients started DAAs. Nine patients discontinued treatment or were lost to follow-up before completion; 1 is continuing DAA treatment. Of 48 patients who completed therapy, sustained virologic response (SVR) was achieved in 43 (89.6%). Age and established mental health treatment at intake were associated with SVR. Regular cocaine use was negatively associated with SVR in univariate analysis, but this association was not significant after adjustment for age. Of 30 patients completing DAA therapy with active illicit opioid use at intake, 14 (46.4%) engaged in opioid use disorder (OUD) treatment during therapy, and 9 remained in OUD treatment after completion of DAA treatment.

Conclusions

Loss to follow-up is a challenge for people who inject drugs, but among those who completed treatment, SVR was achieved at a high rate. Mental health treatment may facilitate HCV cure. Conversely, HCV therapy may facilitate engagement in OUD treatment and other services.
Gumming Up The Works: Field Tests of a New Food-Grade Gum as Behavioral Disruptor for Drosophila suzukii (Diptera: Drosophilidae)
Authors: Rossi Stacconi M V , Tait G , Rendon D , Grassi A , Boyer G , Nieri R , Walton V M
Published: March 2020

Drosophila suzukii Matsumura is an economically important pest of small and stone fruits. Its establishment in the Americas and Europe marked an important turning point in crop management programs. Ten years after its first detection, an effective integrated pest management program has yet to be developed and pesticides are mainly used to control this pest. Here we test a new behavioral control tool, with the aim to develop an alternative pest control strategy. A food-grade gum matrix, was evaluated under controlled and open field conditions for its ability to attract the pest and protect the ripening fruit. Here, we report that the gum effectively reduces fruit infestation when used under managed conditions. We show that a single point source can affect D. suzukii behavior over a 3.6 m radius and last for up to 21 d. Open field data reveal that the efficacy of the gum is significantly impacted by water content. We discuss these results in respect to the future implications for D. suzukii management, along with important considerations on gum mechanism of action, possible application strategies and economic suitability for growers.
Targeted Groups, Rape and Dolus Eventualis
Authors: Fry Elinor , van Sliedregt Elies
Published: March 2020

This article discusses a number of substantive law developments at the Extraordinary Chambers in the Courts of Cambodia (ECCC) after the issuance of the trial judgment in Case 002/02 against Nuon Chea and Khieu Samphan. It focuses on three themes emblematic of the Khmer Rouge era’s unique set of facts: the identification of targeted groups, male victims of rape in the context of forced marriage and the mens rea standard of indirect intent or dolus eventualis. These themes are distilled from the most pertinent jurisprudential developments regarding a number of specific crimes and a mode of liability: persecution on political grounds, genocide, other inhumane acts through conduct characterized as rape in the context of forced marriage, extermination and joint criminal enterprise. This article posits that these substantive law developments have an important place in international criminal law’s corpus as a rare stepping stone between the post-World War II trials and the modern-day international criminal courts and tribunals.
Hydraulic traits vary as the result of tip-to-base conduit widening in vascular plants
Authors: Soriano Diana , Echeverría Alberto , Anfodillo Tommaso , Rosell Julieta A , Olson Mark E
Published: March 2020

Plant hydraulic traits are essential metrics for characterizing variation in plant function, but they vary markedly with plant size and position in a plant. We explore the potential effect of conduit widening on variation in hydraulic traits along the stem. We examined three species that differ in conduit diameter at the stem base for a given height (Moringa oleifera, Casimiroa edulis, and Pinus ayacahuite). We made anatomical and hydraulic measurements at different distances from the stem tip, constructed vulnerability curves, and examined the safety–efficiency trade-off with height-standardized data. Our results showed that segment-specific hydraulic resistance varied predictably along the stem, paralleling changes in mean conduit diameter and total number of conduits. The Huber value and leaf specific conductivity also varied depending on the sampling point. Vulnerability curves were markedly less noisy with height standardization, making the vulnerability–efficiency trade-off clearer. Because conduits widen predictably along the stem, taking height and distance from the tip into account provides a way of enhancing comparability and interpretation of hydraulic traits. Our results suggest the need for rethinking hydraulic sampling for comparing plant functional differences and strategies across individuals.
Stress Effector Systems
Authors: McCarty Richard
Published: March 2020

Three interacting peripheral stress effector systems are activated during exposure of humans and other animals to acute as well as chronic stressors. They include the sympathetic-adrenal medullary (SAM) system, the hypothalamic-pituitary-adrenocortical (HPA) axis, and the innate immune system. The SAM system includes the release of norepinephrine from sympathetic nerve terminals and epinephrine from the adrenal medulla. Plasma levels of norepinephrine and epinephrine have been utilized as an index of SAM activity under basal conditions and following exposure to stress. The HPA axis involves release of corticotropin-releasing factor from neurons in the paraventricular nucleus of the hypothalamus, which stimulates adrenocorticotrophic hormone (ACTH) release from the anterior pituitary, followed by cortisol or corticosterone release from the adrenal cortex. The HPA axis is regulated in part by a system of negative feedback loops. The chemical messengers of the innate immune system include proinflammatory (IL-1β‎, IL-6, and TNF-α‎) and anti-inflammatory cytokines (IL-4 and IL-10).
Stress, Development, and Epigenetics
Authors: McCarty Richard
Published: March 2020

For more than 50 years, there has been an interest in the nongenetic transmission of information from parents to their offspring, especially as it relates to the impact of maternal behavior on the development of offspring. One such mechanism to explain this mode of inheritance is through epigenetic alterations in DNA or histone proteins, but without changes in the sequence of DNA base pairs. Another mechanism that alters extranuclear gene expression involves synthesis of non-coding miRNAs. Paternal influences on fetal development may be mediated by signaling molecules contained within microvesicles in semen. Other experiments have focused on the placenta as a partial barrier to elevations in adrenal steroids and other stress-sensitive molecules in blood. These mechanisms also explain in part how experiences of mothers and fathers prior to mating can be conveyed to their offspring and even succeeding generations.
Session 3: Do the Most Important Thing First!
Authors: Sprich Susan E. , Safren Steven A.
Published: March 2020

This chapter is devoted to teaching the adolescent how to manage multiple tasks without becoming distracted or overwhelmed. This chapter describes how to decide on effective calendar and task list systems. Also, it includes information on how to manage multiple tasks. Information is provided about how to set up a prioritization system for tasks.
Session 7: Optimize Your Setting
Authors: Sprich Susan E. , Safren Steven A.
Published: March 2020

Distractions are a problem for people with attention-deficit/hyperactivity disorder (ADHD). This chapter focuses on how to identify environmental distractions when trying to focus on important tasks like homework and how to modify the environment accordingly. There is information presented about the importance of keeping track of important objects (for example, backpack, phone) and how to set up systems for this. Finally, the chapter contains a discussion of how to use reminders to help with staying on task.
Session 9: Self-Coaching
Authors: Sprich Susan E. , Safren Steven A.
Published: March 2020

Self-coaching or cognitive restructuring is a valuable skill for those with attention-deficit/hyperactivity disorder (ADHD). This chapter continues the discussion of the cognitive component of cognitive behavioral therapy (CBT) introduced in the previous chapter. It includes instructions regarding how to review thought records, and it uses a coaching metaphor to discuss various styles of coaching. The chapter concludes with a discussion of how to formulate helpful alternative thoughts to use in place of negative automatic thoughts.
Overcoming ADHD in Adolescence
Authors: Sprich Susan , Safren Steven A.
Published: March 2020

This Therapist Guide is accompanied by a Client Workbook entitled, Overcoming ADHD in Adolescence: A Cognitive Behavioral Approach. The treatment and manuals are designed for clients to complete with the help of a therapist who is familiar with cognitive behavioral therapy (CBT) and/or structured therapeutic approaches. The program is designed to help adolescent clients with attention-deficit/hyperactivity disorder (ADHD) learn skills to help them cope with their ADHD symptoms. Core modules on organizing and planning, reducing distractibility, and adaptive thinking are included, as is an optional module on reducing procrastination. The emphasis is primarily on teaching the adolescent how to learn skills to combat ADHD and function independently. Information is provided regarding how to include parents in the treatment: inviting a parent or parents in at the end of sessions, including parents in goal setting in joint sessions with the adolescent, and optional coaching sessions without the adolescent present. The guide concludes with a discussion of how to help the client maintain the gains that they have made in treatment. The Client Workbook and Therapist Guide include a discussion of how to incorporate technology into the treatment and “signposts of change” sections in each chapter. The manuals include many worksheets and forms as well as a link to an assessment measure that can be used repeatedly to gauge progress in treatment.
Session 10: How Can Parents Help? Second Parent/Adolescent Session
Authors: Sprich Susan E. , Safren Steven A.
Published: March 2020

This chapter discusses the second parent/adolescent session. In this session, a joint meeting is held with the adolescent client and their parent or parents. The main goal of this session is to discuss how the treatment program is going, revisit treatment goals set at the beginning of treatment, and talk about how things are going with the level of parent involvement and the reward system that was developed (if applicable). The chapter also includes information about how to set reasonable expectations for future improvements and continuing to use the skills learned after the treatment program has ended.
Spine
Authors: Levi Allan D.
Published: March 2020

Spine cases form a significant component of the neurosurgery Oral Board Examinations. A familiarity with the common cases is essential in preparing for the boards. Spine includes cases that span from the skull base to the sacrum. Another component of spine includes an understanding of spine stability as well as the use of spinal instrumentation such as cervical plating and pedicle screws. These techniques are now a standard part of the neurosurgical armamentarium. Current new technologies or approaches to the spine whether minimally invasive techniques or surgery for deformity are actively used and will continue to form a larger part of the oral exam. The following cases are discussed in this chapter: bilateral cervical facet dislocation with spinal cord injury, central calcified thoracic disc herniation, L5 congenital spondylolysis with spondylolisthesis, metastatic lesion, and a thoracolumbar spine deformity.
Neuropsychologist, 5 years’ experience, Germany
Authors: Reuber Markus , Rawlings Gregg H. , Schachter Steven C.
Published: March 2020

This chapter suggests clinicians should distinguish between psychogenic non-epileptic seizures (PNES) and non-epileptic seizures (NES) of undetermined origin. In the case of conditions that probably emerge on the basis of identified psycho-trauma, the diagnosis should rather be posttraumatic stress disorder (PTSD) with PNES as major symptoms. In cases of NES of undetermined origin, physicians should be honest and admit to the patient that they understand neither the nature of the condition nor its causes. Also, the term “dissociative seizures” should be avoided in these cases. The unknown etiology of the condition unfortunately implies that there is no therapy at this stage of the disease. One should avoid unsettling patients with an incomprehensible psychopathological diagnosis and sending them on an endless journey through probably useless psychotherapies.
Nurse, 1 year’s experience, UK
Authors: Reuber Markus , Rawlings Gregg H. , Schachter Steven C.
Published: March 2020

This chapter describes the experience of a Mental Health Nurse at a tertiary neuroscience unit in the UK. In nearly two years of working at the unit, the nurse has not encountered many patients with non-epileptic seizures. As such, the nurse’s main reaction to these patients is uncertainty. It is very hard for the nurse to understand that a psychological response can produce a seizure. Moreover, the nurse often assumes that all patients with non-epileptic seizures have a personality disorder of some kind. The distrust toward these patients is partly because the nurse has no concept of how the psychological can impinge upon the physical brain, and the driver of the of the nurse’s insensitive inner response to these patients is therefore ignorance of the condition. Thus, the likely solution is to learn more about the diagnosis and do as much background reading as possible in an effort to overcome one’s own ignorance—or at the very least, construct some good counterarguments to deploy against one’s own ignorant thoughts.
Neurologist, 5 years’ experience, Azerbaijan; Neurologist, 30 years’ experience, Turkey
Authors: Reuber Markus , Rawlings Gregg H. , Schachter Steven C.
Published: March 2020

This chapter highlights how Psychogenic Non-Epileptic Seizures (PNES) are frequent and difficult situations that should be distinguished from epileptic seizures. When misdiagnosed as epilepsy, patients with PNES are faced with serious and multidimensional difficulties, such as delayed appropriate treatment, adverse effects of long-term antiepileptic drugs (AED), and the financial burden they have to face. Moreover, PNES may be misdiagnosed with status epilepticus (SE), leading to interventions with potentially serious consequences, such as an admission to the intensive care unit (ICU) and intubation. The importance of continuous EEG monitoring for such episodes and evaluation by a clinical neurophysiologist is stressed. In cases such as PNES attacks triggered by convulsive syncope, multidimensional evaluation is necessary. Factors such as life events and psychological traumas should also be taken into consideration.
Neurologist, 8 years’ experience, USA
Authors: Reuber Markus , Rawlings Gregg H. , Schachter Steven C.
Published: March 2020

This chapter offers advice to providers caring for patients with Non-Epileptic Seizures (NES). Care providers should respect the patients and allow them to take the lead in the diagnostic and therapeutic process. Motivational interviewing techniques, such as reflective listening, in which the clinician reflects back the patient’s stated feelings and reasons for change, are critical in supporting patients to engage with and adhere to the therapeutic process. The author vividly remembers a clinical appointment with a patient who was lost in her somatic symptoms, overcome with headaches and auditory hallucinations of a loud bang, and unable to engage in a discussion of her diagnosis. When the author stopped trying to educate the patient about her diagnosis and asked her how the seizures affected her life, reflecting back her responses and pain, the headaches and hallucinations resolved and she was able to engage fully in a conversation about her NES and plans for treatment. Ultimately, caring for patients with NES is often a heavy burden, but it is also a privilege and a blessing—it is what healthcare should be, something that is easy to lose in the modern medical system.
Neurologist, 29 years’ experience, USA
Authors: Reuber Markus , Rawlings Gregg H. , Schachter Steven C.
Published: March 2020

This chapter details how patients with Psychogenic Non-Epileptic Pseudoseizures present some of the more challenging cases brought to a specialist in clinical epilepsy or neurophysiology. One particular case taught a neurologist several important points about the evaluation of those who have psychogenic symptoms. First, an unreliable history is a finding. Second, examination techniques may help separate physiological from functional deficits. Third, despite these careful observations, the patient may not appreciate the efforts. The chapter then specifically looks at a case where a woman presented to the epilepsy monitoring unit with a several year history of paroxysmal events consisting of a metallic taste, bilateral scintillating scotomas, left arm posturing, and loss of consciousness with shaking. Postictal symptoms consisted of headache, amnesia, and severe fatigue. Injuries were also common. In fact, she had been intubated at least twice for status epilepticus. She was also deaf. Later, the neurologist found out that the patient had a history of sexual abuse and had seen a psychiatrist in the past for posttraumatic stress disorder (PTSD). The neurologist thus considered her history as unreliable.
Psychiatric Consultation Liaison Clinical Nurse Specialist, 26 years’ experience, USA
Authors: Reuber Markus , Rawlings Gregg H. , Schachter Steven C.
Published: March 2020

This chapter focuses on the experience of a Psychiatric Clinical Nurse Specialist, who was invited by a Neurologist to help his team with the process of Psychogenic Non-Epileptic Seizure (PNES) diagnostic disclosure. Often, their patients are aware of trauma, such as physical or emotional abuse, incest, and rape; patients report they told a parent, usually their mother, but often they were told it did not happen and never to speak of it again. Other times, there is little or no memory of their childhood at all. The patients also report poor treatment in their local emergency room. Anytime family members have the perception that their loved one is “faking” the events, this will likely result in a lack of family support. Family members can be very helpful as the patient may minimize the sadness/anger felt about a loss. The chapter then offers advice to aid patients’ and family members’ acceptance of the psychogenic diagnosis.
Psychiatrist, 6 years’ experience, Australia
Authors: Reuber Markus , Rawlings Gregg H. , Schachter Steven C.
Published: March 2020

This chapter explores the challenge of working with patients with Non-Epileptic Seizures (NES), which starts with the very name—what to call it, whether it is reasonable to call a condition by what it is not. More challenging is when and if the patient has comorbid epilepsy. The next task is to inform the patient. Working in a tertiary hospital means that the majority of patients have already seen various specialists and the idea might not be completely new to them. However, this does not make the task any easier. If possible, having both the Psychiatrist and the Neurologist together to discuss the diagnosis for the first time can help. Often, the patients are astonished when a Psychiatrist talks to them about “stress seizures,” and they respond with, “But I am not stressed.” Of course, many patients cannot express their anxiety and transform it instead, hence their physical symptoms arise, which in this case are seizures. The saga of NES continues when the focus moves on to treatment, as many times patients need time to come to terms with the very first step of accepting the diagnosis.
Psychologist, 2 years’ experience, USA; Psychologist, 5 years’ experience, USA
Authors: Reuber Markus , Rawlings Gregg H. , Schachter Steven C.
Published: March 2020

This chapter presents a case with compelling evidence for frontal lobe epilepsy (FLE) and Psychogenic Non-Epileptic Seizures (PNES) to address the difficulties providers encounter in helping families receive a definitive diagnosis and eventual path forward. The patient in question was a teenage Caucasian female seeking a third opinion for paroxysmal events. Her father had requested an evaluation to rule out epilepsy after having been told twice before that his daughter’s episodes were likely to be psychogenic in nature. Evidence subsequently obtained over the course of her three-day video-EEG hospitalization provided support for both epilepsy and PNES. The chapter then argues that every adolescent and young adult with epilepsy would benefit from a holistic approach to seizure management, one that takes into account the patient’s quality of life, psychosocial well-being, and relationship with school, family, and friends.
Neurologist, 6 years’ experience, China; Neurosurgeon, 10 years’ experience, China
Authors: Reuber Markus , Rawlings Gregg H. , Schachter Steven C.
Published: March 2020

This chapter assesses the complexity of the diagnosis of Psychogenic Non-Epileptic Seizures (PNES). First, it is hard to discern a patient with PNES by global impression. Unlike other psychological conditions, a brief inquiry in the outpatient department may well only contribute little to the diagnosis of PNES. Second, PNES can present in many different forms and there is no single, identical feature. Symptoms of PNES are usually described as theatrical or thought to change often, but this is not always the case. Especially in patients with variable symptoms, it would be unreliable to draw firm conclusions based on one or two attacks. Third, PNES and epilepsy may coincide. In such cases, it is both tricky to make a diagnosis and even harder to persuade the patient to accept psychotherapy.
Psychologist, 1 year’s experience, Germany
Authors: Reuber Markus , Rawlings Gregg H. , Schachter Steven C.
Published: March 2020

This chapter looks at two stories of patients with dissociative seizures. The first one is about a little boy who was wearing a unicorn costume when the author saw him. The little boy told the author that he was a tricorn. During the course of his stay on the author’s ward, it became clear that he had dissociative seizures in addition to his epileptic seizures. This was probably because he was physically attacked by some boys at school and did not want to go back. Indeed, when asked what he would choose if he had three wishes, the boy said he would wish for a nice house, a lot of money to pay for a private school, and good friends. The second story is about an 18-year-old girl who suffered from dissociative seizures and was on the children’s ward. She was slowly being prepared for the adult ward for patients with Non-Epileptic Seizures. However, she insisted that she wanted to stay in the children’s ward.
Social and Environmental Pedagogue, 15+ years’ experience, Germany
Authors: Reuber Markus , Rawlings Gregg H. , Schachter Steven C.
Published: March 2020

This chapter assesses the experiences of a social and environmental pedagogue with patients with Psychogenic Non-Epileptic Seizures (PNES) while working on a psychotherapeutic ward in an epilepsy center. These experiences mostly involve women with serious traumatic experiences, with a diagnosis of Posttraumatic Stress Disorder (PTSD) and resulting Dissociative Disorders, with dissociative attacks, and even with dissociative fugue states. These women often experience long-lasting seizure states, with dramatic dynamic manifestations, including screams, beating, and defensive or protective movements, in which contents of the traumatic experiences are re-enacted. As such, it is important to adopt an inner attitude that conveys safety and makes it possible to establish a connection with the person concerned. This makes it possible to talk about the seizures/states with the person affected after the seizure has passed, so that the person concerned manages to gain more control over his or her dissociative seizures/states.
Nurse, 30+ years’ experience, Germany
Authors: Reuber Markus , Rawlings Gregg H. , Schachter Steven C.
Published: March 2020

This chapter highlights the importance of how attendants accompany and support patients in seizure situations. One patient, in particular, found it helpful if attendants addressed her during her seizures and did not leave her alone. With prompting, she was able to ease the stiffening of her body and gradually relax. Often, seizures were followed by a short sleep. Afterward, it was possible to discuss the situation and how attendants had interacted with her during the seizure. The long time gaps in her recollection, which had previously always occurred due to the medications she had been given and which had been the cause of some of her uncertainty, could be avoided. Over time, the patient was able to take on a greater level of responsibility for herself.
Neurologist, 13 years’ experience, Italy
Authors: Reuber Markus , Rawlings Gregg H. , Schachter Steven C.
Published: March 2020

This chapter studies how challenging it is to communicate a diagnosis of Psychogenic Non-Epileptic Seizures to patients. This could be due to the inability of one’s reasoning to get rid of the dualistic distinction of the mind from the brain. Plato was the first to believe that the soul, this indistinct, immaterial, and immortal entity devoid of any physical property, was imprisoned in the human body. Since then, this view has become deeply rooted among laypeople and even in the scientific community. The “substance dualism” was further elaborated by René Descartes in the seventeenth century and has its counterpart in the “mind–brain identity theory” discussed in modern Philosophy and Psychology. This dualism underlies the divide between Neurology and Psychiatry and has dissolved their harmonious primeval unity. Neurology is nowadays devoted to the diagnosis and treatment of disorders of the brain, whereas Psychiatry focuses on problems of the mind, as if it were possible to separate what, in reality, are two sides of the same coin. Hopefully, a better understanding of Psychogenic Non-Epileptic Seizures will bring people a step closer to producing a unified view of the human being.
Doctor, over 2 years’ experience, UK
Authors: Reuber Markus , Rawlings Gregg H. , Schachter Steven C.
Published: March 2020

This chapter examines the experiences of a doctor in treating seizures, which has been a constant learning curve. On reflection, the doctor can see that, as a medic, the doctor often analyzes a situation by visualizing the worst-case scenario: how and when might this patient deteriorate and potentially die, and how can the doctor stop that from happening. Consequentially, when assessing a patient having a seizure, the doctor tends to assume the cause is epilepsy until proven otherwise. This approach is appropriate when dealing with status epilepticus but less so with cases of Non-Epileptic Seizures (NES). When applied to NES, it can be detrimental, creating an intense medical atmosphere, heightening the patient’s emotions, and, in some cases, increasing behavioral responses. Ultimately, each patient’s mental health problems are different, so there is no straightforward algorithm to follow when a patient is having a NES.
General Practitioner, 7 years’ experience, UK
Authors: Reuber Markus , Rawlings Gregg H. , Schachter Steven C.
Published: March 2020

This chapter details the stories of two patients which illustrate the confusion and uncertainty that surrounds Non-Epileptic Attack Disorder (NEAD). The first patient has multiple health problems. His medical records list the following diagnoses: reflex anoxic seizures, epilepsy, NEAD, Chronic Obstructive Pulmonary Disease (COPD), heart failure, anemia, and a small meningioma. On a busy on-call, he presented with acute confusion, fever, and tachycardia. Once on the ward, he had a prolonged seizure. This was diagnosed as an acute symptomatic seizure and follow-up in the Neurology clinic was arranged. The patient did not attend the follow-up appointment, but he had another seizure a few weeks later in the street. An ambulance took him to the hospital and the very brief discharge summary referred to “dissociative epilepsy.” Unfortunately, the patient declined psychotherapy because the seizures were “not in his mind.” He was equally reluctant to start other antiepileptic drugs in addition to his long list of other medications. Meanwhile, the second patient’s medical records referred to localization-related epilepsy, generalized epilepsy, and NEAD. However, like the first patient, the second patient resisted psychotherapy.
Neurologist, 23 years’ experience, UK
Authors: Reuber Markus , Rawlings Gregg H. , Schachter Steven C.
Published: March 2020

This chapter focuses on the experience of a Neurologist when he saw patients with Dissociative Seizures twenty years ago as a trainee. At that time, the diagnostic label was very clearly “pseudoseizures,” and the prevailing attitude among the senior Neurologists training the Neurologist was that this was a problem closely allied to malingering. The emphasis was on looking for reasons that the events were “not epilepsy,” with no thought of how to understand, explain, or treat the problem. Tales were told of patients who had been threatened with or given painful stimuli, for instance with a large-bore cannula, leading to them “come round.” All this reinforced a culture of negative attitudes and care. Even though the Neurologist did not take part in these activities, it is horrifying to think not only how that was standard practice but also how it still is in many healthcare institutions around the world. Hopefully, high-quality research, especially treatment trials, will be the lever that can slowly lead to a change in attitudes and practice across the whole medical community.