Panic Disorder: Is the PAG Involved?

Data from studies with humans have suggested that abnormalities of midbrain structures, including the periaqueductal gray matter (PAG), could be involved in the neurobiology of panic disorder (PD). The electrical stimulation of the PAG in neurosurgical patients induces panic-like symptoms and the effect of drugs that are effective in the treatment of PD in the simulation of public speaking model of anxiety is in agreement with data from animal models of PD. Structural neuroimaging studies have shown increases in gray matter volume of midbrain and pons of PD patients. There is also evidence of lower serotonin transporter and receptor binding, and increases of metabolism in the midbrain of PD patients. Nevertheless, these midbrain abnormalities can not be considered as specific findings, since neuroimaging data indicate that PD patients have abnormalities in other brain structures that process fear and anxiety

Modulation of Emotional Faces Processing and Its Implication for Depression and Anxiety

Non

Management of the violent or agitated patient

OBJETIVO: Revisar as medidas preconizadas para o manejo de pacientes agitados ou agressivos. MÉTODO: Por meio de uma busca em bancos de dados (PubMed e Web of Science) foram identificados artigos empíricos e revisões sobre intervenções farmacológicas e não farmacológicas para o manejo de agitação e/ou violência. RESULTADOS: O manejo não farmacológico de agitação/agressão engloba a organização do espaço físico e a adequação de atitudes e comportamentos dos profissionais de saúde. O objetivo principal do manejo farmacológico é a tranquilização rápida, buscando a redução dos sintomas de agitação e agressividade, sem a indução de sedação profunda ou prolongada, mantendo-se o paciente tranquilo, mas completa ou parcialmente responsivo. A polifarmácia deve ser evitada e as doses das medicações devem ser o menor possível, ajustadas de acordo com a necessidade clínica. A administração intramuscular de medicação deve ser considerada como última alternativa e as opções de uso de antipsicóticos e benzodiazepínicos são descritas e comentadas. O manejo físico, por meio de contenção mecânica, pode ser necessário nas situações de violência em que exista risco para o paciente ou equipe, e deve obedecer a critérios rigorosos. CONCLUSÃO: Os procedimentos devem ser cuidadosamente executados, evitando complicações de ordem física e emocional para pacientes e equipe.OBJECTIVE: To review current data about the management of agitated or aggressive patients. METHOD: Through a search of databases (PubMed and Web of Science), empirical articles and reviews about pharmacological and non-pharmacological interventions for the management of agitation and /or violence were identified. RESULTS: The non-pharmacological management of agitation/aggression encompasses the organization of space and appropriateness of behavior and attitudes of health professionals. The main goal of pharmacological management is rapid tranquilization aimed at reducing symptoms of agitation and aggression, without the induction of deep or prolonged sedation, keeping the patient calm, but completely or partially responsive. Polypharmacy should be avoided, and doses of medications should be as small as possible, adjusted according to clinical need. Intramuscular administration of medication should be considered as a last resort and the options for the use of antipsychotics and benzodiazepines are described and commented. The physical management by means of mechanical restraint may be necessary in violent situations where there is risk to the patient or staff, and must meet strict criteria. CONCLUSION: Procedures must be carefully implemented to avoid physical and emotional complications for patients and staff

Effect of changes to the formal curriculum on medical students' motivation towards learning: a prospective cohort study

BACKGROUND: One of the factors known to influence performance in the learning process is student motivation. In turn, students' motivation can be regulated by a large number of variables relating to the individual (such as sex, age and socioeconomic status) or to aspects of the academic life.OBJECTIVE: The primary aim of this study was to evaluate the influence of curriculum changes involving reduction in content overload and increased early exposure to clinical settings, on motivation towards learning among Year 1 medical students. Secondarily, the aim was to ascertain whether this influence on motivation remained stable until the undergraduate program ended (Year 6).DESIGN AND SETTING: Prospective study on two student cohorts at a Brazilian state-owned university.METHODS: Two consecutive student cohorts were assessed: one with a traditional curriculum (n = 87) and the other with a reformed curriculum (n = 63), at the same medical school. Participants in both cohorts gave responses on four scales in Years 1 and 6: the Academic Motivation Scale, containing subscales for autonomous and controlled motivation, and lack of motivation towards learning; Beck's Anxiety and Depression Inventories; Spielberger's State Trait Anxiety Inventory; and the Social Adjustment Scale. In Year 6, 68% of the initial sample (66 students with the traditional curriculum and 36 with the reformed curriculum) was reassessed.RESULTS: No differences between Year 1 cohorts were found regarding demographic and social background, social adjustment, depression or anxiety. Students with the reformed curriculum scored significantly higher regarding autonomous and controlled motivation than those with the traditional curriculum. Comparison between Year 6 and Year 1 showed increases in controlled motivation only for the traditional curriculum cohort.CONCLUSION: Curriculum changes were associated with increased motivation towards learning inYear 1, which persisted until Year 6.Cristina Marta Del-Ben is supported by a research fellowship grant (level 1C) from Conselho Nacional de Desenvolvimento Cientifico e Tecnologico (CNPq; protocol number 307492/2014-1

Similar reduction of cholesterol-adjusted Vitamin E serum levels in simple steatosis and non-alcoholic steatohepatitis

OBJECTIVES: Reduced vitamin E levels have been reported in patients with non-alcoholic steatohepatitis (NASH), but no conclusive data on patients with simple steatosis (SS) are available. Aim of this study was to investigate the association betweenserum vitamin E levels and SS. METHODS: A cohort of 312 patients with cardio-metabolic risk factors was screened for liver steatosis by ultrasonography (US). We reasonably classified as SS patients with US-fatty liver, normal liver function tests (LFTs) and with Cytokeratin 18 o246 mIU/ml. Liver biopsy was performed in 41 patients with US-fatty liver and persistent elevation of LFTs (46 months). Serum cholesterol-adjusted vitamin E (Vit E/chol) levels were measured. RESULTS: Mean age was 53.9±12.5 years and 38.4% were women. Non-alcoholic fatty liver disease (NAFLD) was detected at US in 244 patients; of those 39 had biopsy-proven NASH and 2 borderline NASH. Vit E/chol was reduced in both SS (3.4±2.0, Po0.001), and NASH (3.5±2.1, P=0.006) compared with non-NAFLD patients (4.8±2.0 μmol/mmol chol). No difference was found between SS and NASH (P=0.785). After excluding patients with NASH, a multivariable logistic regression analysis found that Vit E/chol (odds ratio (OR): 0.716, 95% confidence interval (CI) 0.602–0.851, Po0.001), alanine aminotransferase (ALT, OR: 1.093, 95% CI 1.029–1.161, P=0.004), body mass index (OR: 1.162, 95% CI 1.055–1.279, P=0.002) and metabolic syndrome (OR: 5.725, 95% CI 2.247–14.591, Po0.001) were factors independently associated with the presence of SS. CONCLUSIONS: Reduced vitamin E serum levels are associated with SS, with a similar reduction between patients with SS and NASH, compared with non-NAFLD patients. Our findings suggest that the potential benefit of vitamin E supplementation should be investigated also in patients with SS

Differential diagnosis of first episode psychosis: importance of optimal approach in psychiatric emergencies

OBJETIVO: Revisar dados da literatura relativos ao diagnóstico de primeiro episódio psicótico no contexto das emergências psiquiátricas. MÉTODO: Revisão de artigos empíricos e de revisão selecionados por meio de busca eletrônica no indexador PubMed. RESULTADOS: Características específicas de atendimento de emergência - avaliação única e breve, em corte transversal e com poucas informações disponíveis - podem dificultar o processo diagnóstico. Essas limitações podem ser contornadas por meio da aplicação adequada de critérios diagnósticos operacionais, do uso de escalas e entrevistas diagnósticas padronizadas e de um tempo mínimo de observação de 24 a 72 horas. Diagnósticosdetranstornobipolar,esquizofrenia,depressãopsicóticaetranstorno delirante elaborados em contexto de emergência apresentam boa estabilidade temporal, não ocorrendo o mesmo com diagnósticos de transtorno psicótico breve, transtorno esquizofreniforme e transtorno esquizoafetivo. Primeiro episódio psicótico pode ocorrer na vigência do uso de substâncias psicoativas, sendo relativamente frequente a manutenção do quadro psicótico mesmo após cessação do uso. A utilização racional de exames complementares pode ajudar no diagnóstico diferencial com episódios psicóticos devido a condições médicas gerais. CONCLUSÃO: Diagnósticos de primeiro episódio psicótico podem ser adequadamente realizados durante emergências psiquiátricas, desde que sejam implementadas rotinas baseadas em evidências científicas.OBJECTIVE: To review the literature regarding the diagnosis of first episode psychosis in the context of emergency psychiatry. METHOD: Review of empirical and review articles selected by electronic search in the database PubMed. RESULTS: Specific features of emergency care - single, brief and cross section assessment, and with little information - may jeopardize the diagnostic process. These limitations can be circumvented by application of operational diagnostic criteria, the use of scales and structured interviews and a short period of observation, between 24-72 hours. Diagnoses of bipolar disorder, schizophrenia, psychotic depression and delusional disorder developed in the context of emergency have good stability, but not the diagnoses of brief psychotic disorder, schizophreniform disorder and schizoaffective disorder. First episode psychosis can occur in the course of the use of psychoactive substances, with relatively frequent maintenance of psychotic symptoms even after cessation of the use of the substance. The rational use of subsidiary tests may help the differential diagnosis of psychotic episodes due to general medical conditions. CONCLUSION: Diagnoses of first psychotic episode can be adequately performed during psychiatric emergencies, if routines are implemented based on scientific evidence

A web-based information system for a regional public mental healthcare service network in Brazil

Acknowledgements We would like to thank all the participating representatives of public mental health services for their invaluable contribution to this system development and implementation and the XIII Regional Health Department of Sao Paulo state for their support. Funding: This study was funded by the ‘Conselho Nacional de Desenvolvimento Científico e Tecnológico’ (CNPq) and ‘Coordenação de Aperfeiçoamento de Pessoal de Nível Superior’ (CAPES)—Science Without Borders Programme.Peer reviewedPublisher PD

Correlation between voxel based morphometry and manual volumetry in magnetic resonance images of the human brain

This is a comparative study between manual volumetry (MV) and voxel based morphometry (VBM) as methods of evaluating the volume of brain structures in magnetic resonance images. The volumes of the hippocampus and the amygdala of 16 panic disorder patients and 16 healthy controls measured through MV were correlated with the volumes of gray matter estimated by optimized modulated VBM. The chosen structures are composed almost exclusively of gray matter. Using a 4 mm Gaussian filter, statistically significant clusters were found bilaterally in the hippocampus and in the right amygdala in the statistical parametric map correlating with the respective manual volume. With the conventional 12 mm filter,a significant correlation was found only for the right hippocampus. Therefore,narrowfilters increase the sensitivity of the correlation procedure, especially when small brain structures are analyzed. The two techniques seem to consistently measure structural volume.Trata-se de estudo comparativo entre a volumetria manual(VM) e a morfometria baseada no vóxel (MBV), como métodos de avaliação do volume de estruturas cerebrais. Os volumes do hipocampo e da amídala de 16 pacientes de pânico e 16 controles sadios medidos através da VM foram correlacionados com os volumes de matéria cinzenta estimados pela MBV.As estruturas escolhidas são constituídas quase exclusivamente de matéria cinzenta. Utilizando um filtro Gaussiano de 4 mm, encontram-se, bilateralmente, aglomerados significativos de correlação nas duas estruturas no mapa estatístico paramétrico, correspondendo ao respectivo volume manual. Com o filtro convencional de 12 mm, apenas uma correlação significativa foi encontrada no hipocampo direito. Portanto, filtros estreitos aumentam a sensibilidade do procedimento de correlação,especialmente quando estruturas pequenas são analisadas. Ambas as técnicas parecem medir consistentemente o volume estrutural.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)(FAEPA) Hospital das Clínicas da FMRPUSP - Fundação de Apoio ao Ensino, Pesquisa e Asssistênci

S14. DNA methylation changes in GABAergic and glutamatergic markers in early schizophrenia.

Background: GABAergic and glutamatergic systems play an important role in the neurobiology of schizophrenia, and changes in their markers are reported in both postmortem human brain and in animal models. Recent studies have demonstrated that abnormalities in DNA methylation may underlie the alterations in various indicators of GABAergic and glutamatergic functions in schizophrenia. As our group previously found decreased NR2 protein plasma levels and downregulation of parvalbumin (PVALB) mRNA in first episode of psychosis (FEP) patients, we hypothesised that changes in DNA methylation may be responsible for these indicators of glutamatergic and GABAergic deficits in FEP patients. Methods: Blood samples were collected from patients in FEP (n = 35) after their first contact with the mental health assistance, siblings (n = 21) and population-based controls (n = 35). Bisulfite conversion and pyrosequencing were used to determine methylation levels in 4 CpG sites in promoter sequence of PVALB and 5 CpG sites at GRIN2B (gene which encodes NR2). Results: We found hypermethylation at a CpG site within the PVALB promoter sequence in patients and their siblings compared to population-based control group (p< 0.001) while overall hypomethylation was found in the 5 CpGs analysed within GRIN2B promoter sequence (p < 0.01). Discussion: Our PVALB findings are consistent with our previous studies showing that PVALB promoter methylation is elevated in schizophrenia and, additionally this is the first evidence showing changes in GRIN2B promoter methylation in psychosis. These results together suggest that these epigenetic findings may relate to the reduction of protein expression of indicators of glutamate and GABA systems seen in this disease