Variations in cognitive functioning in genetic generalized epilepsy: four case studies

Introduction. The traditional view of cognition in idiopathic or genetic generalized epilepsy (GGE) is that "one size fits all" i.e. only very mild generalized impairment might be detected, if any. This paper describes four case studies of cognitive functioning in GGE patients with photosensitivity and reflexive seizures. Aim. The aim was to discover whether each individual's set of cognitive deficits varied in accordance with his/her other clinical phenomena such as photosensitivity and kinds of reflexive seizures. Method. Neurological and cognitive performance was assessed by comprehensive evaluation of each patient based on interviews, neurologist's EEG reports and neuropsychological tests. Assessment of cognitive domains included estimated pre-morbid I.Q. based on reading ability and demographic norms, current I.Q., attention factors, verbal memory, visual memory and executive functions. Results. Clinical signs and investigative studies indicated that two cases typically began reflexive seizure episodes with facial myoclonia which evolved into tonic-clonic convulsions or generalized myoclonic seizures. These patients had widespread attention and working memory deficits, some severe, together with lowered intelligence scores. In contrast, two other cases (with no history of myoclonus) had generalized reflexive seizures originating in the occipital lobes, very mild localized visual dysfunction and high intelligence. Conclusions. The systematic variation in extent and nature of cognitive dysfunction illustrated in these cases with reflexive seizures (preceded by myoclonia or visual phenomena) would be explained by a more recent conceptualization of GGE as encompassing regional differences in variable hyperexcitability located at cortical levels or functional neural networks

Efficacy of inpatient psychotherapy for major depressive disorder: a meta-analysis of controlled trials

Fragestellung: In dieser Metaanalyse soll die Wirksamkeit stationärer Psychotherapie depressiver Störungen im Vergleich zu Kontrollbedingungen ohne psychotherapeutische Intervention beurteilt werden. Dabei werden Faktoren wie Art der Kontrollbedingung, die Verwendung von Fremd- bzw. Selbstbeurteilungsskalen und die Anzahl an Therapieeinheiten als moderierende Variablen berücksichtigt. Methode: Ein systematische Suche in vier biomedizinsichen Datenbanken (CENTRAL, PsycINFO, MEDLINE, Web of Science) wurde unternommen. Als primärer Endpunkt galt die Differenz der Depressionsschwere zwischen der Interventions- und Kontrollbedingung ermittelt durch Selbstbeurteilungsskalen, die in einer random effects Metaanalyse zusammengefasst wurden. In Subgruppenanalysen wurden Studien mit verschiedenen Arten von Kontrollbedingungen verglichen, wobei unterschieden wurde zwischen a) keine Behandlung (z.B.Warteliste), b) treatment as usual (TAU) - nicht durch die Studie standardisiert und c) TAU - manualisiert, durch die Studie standardisiert. Ferner wurden Studien mit 21 Therapieeinheiten, sowie Ergebnisse von Selbst- und Fremdbeurteilungsmaßen verglichen. Eine Prüfung auf einen Publikationsbias der Metaanalyse und eine Bewertung des Risikos systematischer Verzerrungen innerhalb der einzelnen Studien wurde vorgenommen. Resultate: Es wurden 14 relevante Studien (k = 19 Vergleiche) mit insgesamt 1080 Patienten gefunden. Die Metaanalyse wies eine kleine, statistisch signifikante Überlegenheit der stationären Psychotherapie gegenüber Kontrollbedingungen ohne Psychotherapie aus (g = 0.24, p < 0.001, I^2 = 0%, NNT = 7.4). Die Effekte der Intervention zeigten sich über eine Periode von mindestens 12 Monaten stabil (k = 9, n = 710, g = 0.21, p = 0.04, I^2 = 30%). Im Subgruppenvergleich von stationärer Psychotherapie mit standardisierten Kontrollbedingungen zeigte sich keine Überlegenheit der Psychotherapie. Im Vergleich zu Warteliste oder unstandardisiertem TAU blieb der Effekt bestehen. Eine höhere Anzahl an Therapiesitzungen zeigte tendenziell geringere Effekte. Ergebnisse von Fremd- und Selbstbeurteilungmaßen unterschieden sich marginal. Es fand sich keine Evidenz für einen Publikationsbias. Schlussfolgerung: Ein kleiner jedoch robuster und anhaltender Effekt stationärer Psychotherapie gegenüber einer gewöhnlichen stationäre Krankenhausbehandlung konnte für depressive Störungen gezeigt werden. Der Effekt war in einer Subgruppe von Studien mit stärker standardisierten Kontrollbedingungen nicht mehr nachzuweisen.Objective: This meta-analysis aims to investigate the efficacy of inpatient psychotherapy of depressive disorders compared to control conditions without psychotherapy. As moderating factors, we consider the type of control condition, use of self- vs clnician ratings and number of treatment sessions. Methods: A systematic search of four biomedical databases (CENTRAL, PsycINFO, MEDLINE, Web of Science) was performed. The differences in self-rated depression severity between intervention and control groups served as primary outcomes, which were synthesized in a random effects meta-analysis. In subgroup analyses, studies were compared based on differences in the type of control conditions they applied. We distinguished a) no treatment or waitlist controls, b) treatment as usual (TAU) - not standardized by trial design, c) TAU - standardized by trial design, manualized. Subgroups of trials providing 21 treatment sessions were compared as well as results from self- versus clinician ratings. Results: Fourteen relevant studies (k = 19 comparisons) with a total of 1080 patients were retrieved. The meta-analysis showed a small, statistically significant superiority of inpatient psychotherapy compared to control conditions without psychotherapy (g = 0.24, p < 0.001, I^2 = 0%, NNT = 7.4). The effects of the intervention were stable over a minimum12-months follow-up period (g = 0:21; p = 0:04; I2 = 30%). In subgroup comparisons of inpatient psychotherapy to manualized and standardized control conditions, no superiority of psychotherapy was shown. Compared to waitlist and non-standardized TAU the significant effect remained. A higher number of treatment sessions showed trendwise smaller effects. Results between self- and clnician ratings differed only marginally. There was no evidence of a publication bias. Conclusions: We found evidence for a small but robust and lastig effect of inpatient psychotherapy in patients with depressive disorders when compared to treatment as usual. The effect was not present in a subgroup of studies using more standardized control conditions

Efficacy and acceptability of third-wave psychotherapies in the treatment of depression: a network meta-analysis of controlled trials

IntroductionIn recent decades, various new psychotherapy approaches have been developed in an effort to overcome issues of non-response, referred to as “third-wave psychotherapies.” How third-wave therapies perform in comparison to each other, to classical CBT, or other common comparators in the treatment of depression has not yet been systematically assessed.MethodsWe firstly determined the scope of the term “third-wave” by conducting a systematic search. The identified approaches were then used as search terms for the systematic review and network meta-analysis (NMA). We searched MEDLINE, CENTRAL, PsychINFO and Web of Science from inception until 31 July 2022. We assessed randomized controlled trials comparing third-wave psychotherapies to each other, CBT, treatment as usual (TAU), medication management, active control conditions, or waitlist (WL) in adult populations with depressive disorders. The treatments included were acceptance and commitment therapy, behavioral activation, cognitive behavioral analysis system of psychotherapy, dialectical behavioral therapy, mindfulness-based cognitive therapy, meta-cognitive therapy, positive psychotherapy and schema therapy. The primary outcome was depression severity (efficacy) at study endpoint, and the secondary outcome was all-cause discontinuation (acceptability). This review was registered in PROSPERO, identifier CRD42020147535.ResultsOf 7,971 search results, 55 trials were included in our NMA (5,827 patients). None of the third-wave therapies were more efficacious than CBT but most were superior to TAU [standardized mean differences (SMD) ranging between 0.42 (95% CI −0.37; 1.19) and 1.25 (0.48; 2.04)]. Meta-cognitive therapy (MCT) was more efficacious than three other third-wave therapy approaches. None of the third-wave treatments were more acceptable than WL or CBT. Twenty-seven percent of the trials were rated as low risk of bias. Confidence in the evidence was largely low according to GRADE. Inconsistency emerged for a small number of comparisons.InterpretationsThird-wave therapies are largely efficacious and acceptable alternatives to CBT when compared to TAU, with few differences between them. The evidence so far does not point toward superiority or inferiority over CBT. Patient-level research may offer possibilities for tailoring individual psychotherapies to the needs of individual patients and future trials should make this data available. The evidence base needs to be broadened by sufficiently powered trials

Improving Early Antibiotic Administration for Treatment of Sepsis at Children’s Hospital of Richmond at VCU: 2012-2019

Background: The Surviving Sepsis Campaign recommends initiating IV antibiotic administration within one hour of recognition of severe sepsis. Several studies have shown that prompt blood culture collection, administration of broad-spectrum antibiotics, and fluid resuscitation following recognition improves child survival. Objective: Our goal was to evaluate effectiveness of sepsis initiatives and institutional changes in the timing of early antibiotic administration at Children’s Hospital of Richmond at VCU. Methods: We formed a Pediatric Sepsis Committee with representatives from each unit in 2013. In 2016, the committee began tracking time from the order of a first stat dose IV antibiotic to administration as a marker of early treatment and reviewed data on a monthly basis with run charts for overall and unit-specific data. Other interventions included improved availability of antibiotics in automated dispensing machines, sepsis screening and alert systems, sepsis huddles, and auto-generated pages to charge nurses upon order of stat IV antibiotics. We included percent of stat antibiotics administered in less than one hour from order across all pediatric units since 2012. Results: Across all units, the centerline of first dose stat antibiotics delivered within one hour improved from a baseline of 34% in 2012 to 76% in 2019. The NICU and PICU centerlines improved by 53% and 48%, respectively since 2012. The Pediatric ED improved from 66% in 2012 to 84% in 2016. The Acute Care Pediatrics (ACP) Unit centerline improved from 24% in 2012 to 50% in 2017. Conclusion: Time from order to stat antibiotic administration has improved in all units receiving quality improvement initiatives. These improvements have been made possible by widespread emphasis on the dangers of untreated sepsis, multidisciplinary collaboration between nursing and physician staff, structural pharmacy changes and electronic alerts. Further studies are needed to determine impact on patient outcomes

Videogame-based group therapy to improve self-awareness and social skills after traumatic brain injury

[EN] Background: This study determines the feasibility of different approaches to integrative videogame-based group therapy for improving self-awareness, social skills, and behaviors among traumatic brain injury (TBI) victims and retrieves participant feedback. Methods: Forty-two adult TBI survivors were included in a longitudinal study with a pre- and post-assessments. The experimental intervention involved weekly one-hour sessions conducted over six months. Participants were assessed using the Self-Awareness Deficits Interview (SADI), Patient Competency Rating Scale (PCRS), the Social Skills Scale (SSS), the Frontal Systems Behavior Scale (FrSBe), the System Usability Scale (SUS). Pearson's chi-squared test (χ 2 ) was applied to determine the percentage of participants who had changed their clinical classification in these tests. Feedback of the intervention was collected through the Intrinsic Motivation Inventory (IMI). Results: SADI results showed an improvement in participant perceptions of deficits (χ 2 = 5.25, p < 0.05), of their implications (χ 2 = 4.71, p < 0.05), and of long-term planning (χ 2 = 7.86, p < 0.01). PCRS results confirm these findings (χ 2 = 5.79, p < 0.05). SSS results were also positive with respect to social skills outcomes (χ 2 = 17.52, p < 0.01), and FrSBe results showed behavioral improvements (χ 2 = 34.12, p < 0.01). Participants deemed the system accessible (80.43 ± 8.01 out of 100) and regarded the intervention as interesting and useful (5.74 ± 0.69 out of 7). Conclusions: Integrative videogame-based group therapy can improve self-awareness, social skills, and behaviors among individuals with chronic TBI, and the approach is considered effective and motivating.This study was funded in part by Ministerio de Economia y Competitividad of Spain (Project TEREHA, IDI-20110844; and NeuroVR, TIN2013-44741-R), by Ministerio de Educacion y Ciencia of Spain (Projects Consolider-C, SEJ2006-14301/PSIC; and "CIBER of Physiopathology of Obesity and Nutrition, an initiative of ISCIII"), and by the Excellence Research Program PROMETEO (Generalitat Valenciana. Conselleria de Educacion, 2008-157).Llorens Rodríguez, R.; Noé Sebastián, E.; Ferri, J.; Alcañiz Raya, ML. (2015). Videogame-based group therapy to improve self-awareness and social skills after traumatic brain injury. Journal of NeuroEngineering and Rehabilitation. 12(37):1-9. https://doi.org/10.1186/s12984-015-0029-1S191237Sherer M, Bergloff P, Levin E, High Jr WM, Oden KE, Nick TG. Impaired awareness and employment outcome after traumatic brain injury. J Head Trauma Rehabil. 1998;13(5):52–61.Sherer M, Hart T, Nick TG. Measurement of impaired self-awareness after traumatic brain injury: a comparison of the patient competency rating scale and the awareness questionnaire. Brain Inj. 2003;17(1):25–37.Simmond M, Fleming J. Occupational therapy assessment of self-awareness following traumatic brain injury: a literature review. Br J Occup Ther. 2003;66:447–53.Bogod NM, Mateer CA, MacDonald SWS. Self-awareness after traumatic brain injury: a comparison of measures and their relationship to executive functions. J Int Neuropsychol Soc. 2003;9(03):450–8.Stuss DT, Levine B. Adult clinical neuropsychology: lessons from studies of the frontal lobes. Annu Rev Psychol. 2002;53:401–33.Ham TE, Bonnelle V, Hellyer P, Jilka S, Robertson IH, Leech R, et al. The neural basis of impaired self-awareness after traumatic brain injury. Brain. 2014;137(Pt 2):586–97.Prigatano GP, Schacter DL. Awareness of Deficit After Brain Injury: Clinical and Theoretical Issues. New York: Oxford University Press; 1991.Katz N, Fleming J, Keren N, Lightbody S, Hartman-Maeir A. Unawareness and/or denial of disability: implications for occupational therapy intervention. Can J Occup Ther. 2002;69(5):281–92.Fleming JM, Strong J, Ashton R. Self-awareness of deficits in adults with traumatic brain injury: how best to measure? Brain Inj. 1996;10(1):1–15.Goverover Y, Johnston MV, Toglia J, Deluca J. Treatment to improve self-awareness in persons with acquired brain injury. Brain Inj. 2007;21(9):913–23.Bach LJ, David AS. Self-awareness after acquired and traumatic brain injury. Neuropsychol Rehabil. 2006;16(4):397–414.Prigatano GP. Behavioral Limitations TBI patients tend to underestimate: a replication and extension to patients with lateralized cerebral dysfunction. Clin Neuropsychol. 1996;10(2):191–201.Sherer M, Boake C, Levin E, Silver BV, Ringholz G, High WM. Characteristics of impaired awareness after traumatic brain injury. J Int Neuropsychol Soc. 1998;4(04):380–7.Sveen U, Mongs M, Roe C, Sandvik L, Bautz-Holter E. Self-rated competency in activities predicts functioning and participation one year after traumatic brain injury. Clin Rehabil. 2008;22(1):45–55.Crosson B, Barco PP, Velozo CA, Bolesta MM, Cooper PV, Werts D, et al. Awareness and compensation in postacute head injury rehabilitation. J Head Trauma Rehabil. 1989;4(3):46–54.Toglia J, Kirk U. Understanding awareness deficits following brain injury. NeuroRehabilitation. 2000;15(1):57–70.Schrijnemaekers AC, Smeets SM, Ponds RW, van Heugten CM, Rasquin S. Treatment of unawareness of deficits in patients with acquired brain injury: a systematic review. J Head Trauma Rehabil. 2014;29(5):E9–30.Tate R, Kennedy M, Ponsford J, Douglas J, Velikonja D, Bayley M, et al. INCOG recommendations for management of cognition following traumatic brain injury, part III: executive function and self-awareness. J Head Trauma Rehabil. 2014;29(4):338–52.Chittum WR, Johnson K, Chittum JM, Guercio JM, McMorrow MJ. Road to awareness: an individualized training package for increasing knowledge and comprehension of personal deficits in persons with acquired brain injury. Brain Inj. 1996;10(10):763–76.Zhou J, Chittum R, Johnson K, Poppen R, Guercio J, McMorrow MJ. The utilization of a game format to increase knowledge of residuals among people with acquired brain injury. J Head Trauma Rehabil. 1996;11(1):51–61.Ownsworth TL, McFarland K, Mc Young R. Self-awareness and psychosocial functioning following acquired brain injury: an evaluation of a group support programme. Neuropsychol Rehabil. 2000;10(5):465–84.Lundqvist A, Linnros H, Orlenius H, Samuelsson K. Improved self-awareness and coping strategies for patients with acquired brain injury–a group therapy programme. Brain Inj. 2010;24(6):823–32.Schmidt J, Lannin N, Fleming J, Ownsworth T. Feedback interventions for impaired self-awareness following brain injury: a systematic review. J Rehabil Med. 2011;43(8):673–80.Schmidt J, Fleming J, Ownsworth T, Lannin NA. Video feedback on functional task performance improves self-awareness after traumatic brain injury: a randomized controlled trial. Neurorehabil Neural Repair. 2013;27(4):316–24.McGraw-Hunter M, Faw GD, Davis PK. The use of video self-modelling and feedback to teach cooking skills to individuals with traumatic brain injury: a pilot study. Brain Inj. 2006;20(10):1061–8.Ownsworth T, Quinn H, Fleming J, Kendall M, Shum D. Error self-regulation following traumatic brain injury: a single case study evaluation of metacognitive skills training and behavioural practice interventions. Neuropsychol Rehabil. 2010;20(1):59–80.Lucas SE, Fleming JM. Interventions for improving self-awareness following acquired brain injury. Aust Occup Ther J. 2005;52(2):160–70.Malec JF, Brown AW, Leibson CL, Flaada JT, Mandrekar JN, Diehl NN, et al. The mayo classification system for traumatic brain injury severity. J Neurotrauma. 2007;24(9):1417–24.Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189–98.Nakase-Thompson R, Manning E, Sherer M, Yablon SA, Gontkovsky SL, Vickery C. Brief assessment of severe language impairments: initial validation of the Mississippi aphasia screening test. Brain Inj. 2005;19(9):685–91.Prigatano GP, Fordyce DJ. Neuropsychological rehabilitation after brain injury. Baltimore: The Johns Hopkins University Press; 1986.Gismero E. EHS, Escala de habilidades sociales. TEA: Madrid; 2000.Reid-Arndt SA, Nehl C, Hinkebein J. The Frontal Systems Behaviour Scale (FrSBe) as a predictor of community integration following a traumatic brain injury. Brain Inj. 2007;21(13–14):1361–9.Brooke J. SUS: A quick and dirty usability scale. In Usability evaluation in industry. PW Jordan, et al. Editors. Taylor and Francis; 1996Plant RW, Ryan RM. Intrinsic motivation and the effects of self-consciousness, self-awareness, and ego-involvement: An investigation of internally controlling styles. J Pers. 1985;53(3):435–49.Cheng SK, Man DW. Management of impaired self-awareness in persons with traumatic brain injury. Brain Inj. 2006;20(6):621–8.Ownsworth T, Fleming J, Shum D, Kuipers P, Strong J. Comparison of individual, group and combined intervention formats in a randomized controlled trial for facilitating goal attainment and improving psychosocial function following acquired brain injury. J Rehabil Med. 2008;40(2):81–8.Ownsworth T, Fleming J, Desbois J, Strong J, Kuipers P. A metacognitive contextual intervention to enhance error awareness and functional outcome following traumatic brain injury: a single-case experimental design. J Int Neuropsychol Soc. 2006;12(1):54–63.Fleming JM, Lucas SE, Lightbody S. Using occupation to facilitate self-awareness in people who have acquired brain injury: a pilot study. Can J Occup Ther. 2006;73(1):44–55.McDonald S, Tate R, Togher L, Bornhofen C, Long E, Gertler P, et al. Social skills treatment for people with severe, chronic acquired brain injuries: a multicenter trial. Arch Phys Med Rehabil. 2008;89(9):1648–59.Schefft BK, Malec JF, Lehr BK, Kanfer FH. The role of self-regulation therapy with the brain-injured client. In: Maurish ME, Moses JA, editors. Clinical neuropsychology: theoretical foundations for practitioners. Mahwah, NJ: Erlbaum; 1997. p. 237–82.Pollens RD, McBratnie BP, Burton PL. Beyond cognition: executive functions in closed head injury. Cogn Rehabil. 1988;6(5):26–32.Carbery H, Burd B. Social aspects of cognitive retraining in an outpatient group setting for head trauma patients. Cogn Rehabil. 1983;1:5–7.Bennett TL, Raymond MJ. Emotional consequences and psychotherapy for individuals with mild brain injury. Appl Neuropsychol. 1997;4(1):55–61.Delmonico RL, Hanley-Peterson P, Englander J. Group psychotherapy for persons with traumatic brain injury: management of frustration and substance abuse. J Head Trauma Rehabil. 1998;13(6):10–22.Alexy WD, Foster M, Baker A. Audio-visual feedback: an exercise in self-awareness for the head injured patient. Cogn Rehabil. 1983;1(6):8–10.Ranseen JD, Bohaska LA, Schmitt FA. An investigation of anosognosia following traumatic head injury. Int J Clin Neuropsychol. 1990;12(1):29–36.Sasse N, Gibbons H, Wilson L, Martinez-Olivera R, Schmidt H, Hasselhorn M, et al. Self-awareness and health-related quality of life after traumatic brain injury. J Head Trauma Rehabil. 2013;28(6):464–72.Malec JF, Testa JA, Rush BK, Brown AW, Moessner AM. Self-assessment of impairment, impaired self-awareness, and depression after traumatic brain injury. J Head Trauma Rehabil. 2007;22(3):156–66.Fleming JM, Ownsworth T. A review of awareness interventions in brain injury rehabilitation. Neuropsychol Rehabil. 2006;16(4):474–500