Zeina Chemali

It is time to talk about people: a human-centered healthcare system

Examining vulnerabilities within our current healthcare system we propose borrowing two tools from the fields of engineering and design: a) Reasons system approach [1] and b) User-centered design [2, 3]. Both approaches are human-centered in that they consider common patterns of human behavior when analyzing systems to identify problems and generate solutions. This paper examines these two human-centered approaches in the context of healthcare. We argue that maintaining a human-centered orientation in clinical care, research, training, and governance is critical to the evolution of an effective and sustainable healthcare system.

The use of eye movement desensitization and reprocessing in the treatment of psychogenic seizures

We present a case illustrating the use of eye movement desensitization and reprocessing (EMDR) in the treatment of psychogenic seizures. These seizures were events lasting many hours, necessitating frequent emergency room visits and an extensive medical work up. Given the patients history, posttraumatic stress disorder (PTSD) was diagnosed. EMDR is widely used as a treatment modality for PTSD, and the patient was referred for once-per-week treatment, with complete recovery after 18 months of therapy. The impact of her recovery on her quality of life was astonishing. This case supports the notion that EMDR can be an effective alternative treatment for psychogenic seizures, especially when the history reveals a traumatic event or abusive experiences.

The Elderly Safety Imperative and Antipsychotic Usage

&NA; Behavioral and psychotic symptoms are common problems in older adults, and as the population ages, understanding the benefits and risks of antipsychotic usage is increasingly important. In this age group, psychotic symptoms may occur in patients with dementia or as part of schizophrenia, mood disorders, delirium, or delusional disorder. Various antipsychotics have been studied in older adults with psychotic symptoms, demonstrating mixed, but real, benefit, especially in relation to carefully selected patients. Caution is required because of the potential side effects and risks, which include increased mortality and cardiovascular and cerebrovascular events. This article reviews the use of antipsychotics in older adults, with emphasis on the risks and side effects, particularly in dementia patients with behavioral and psychotic symptoms.

Tourette’s syndrome following temporal lobectomy for seizure control

Gilles de la Tourettes syndrome (TS) is a neurobehavioral disorder characterized by multiple motor and vocal tics, occurring longer than a year and causing marked distress along with social and occupational impairments in level of functioning. It can be accompanied by obsessive-compulsive behavior and attention deficit disorder. This report discusses the case of a young woman with a simple motor tic disorder and intractable seizures who, after right temporal lobectomy for medically intractable epilepsy, developed TS with complex motor and vocal tics, severe obsessive-compulsive disorder, and paranoia. This neurobehavioral complication has not to our knowledge been previously reported after epilepsy surgery.

Du rire aux larmes: pathological laughing and crying in patients with traumatic brain injury and treatment with lamotrigine.

Pathologic laughter and crying (PLC) is the involuntary occurrence of laughter and crying in the absence of a corresponding change in affect. PLC resulting from structural brain damage in patients with traumatic brain injury can be the cause of substantial social dysfunction in these patients. The use of lamotrigine as an antiepileptic drug and mood stabilizer is well established; its use in PLC has been reported only once during treatment following a stroke. We present here four young patients with pathological laughter and/or pathological crying following traumatic brain injury who were successfully treated with lamotrigine. Data supporting the use of lamotrigine in the treatment of PLC following traumatic brain injury and the neuroanatomy of pathological laughing are briefly reviewed.

The Use of Selective Serotonin Reuptake Inhibitors in Elderly Patients

&NA; Depression is common among the elderly, and several factors need to be taken into account in selecting the appropriate antidepressant in this age group. Various physiologic changes occur in individuals as they age, potentially leading to changes in the pharmacodynamic and pharmacokinetic properties of drugs in elderly individuals. The efficacy of various medications, their side‐effect profiles, and the potential for drug‐drug interactions may differ in older patients compared to younger ones. The selective serotonin reuptake inhibitors (SSRIs), which are seen as being among the first‐line agents for treatment of depression in elderly patients, have been shown to be effective but carry with them side effects and drug‐drug interactions that warrant special attention when these medications are prescribed to older individuals. This review focuses on the pharmacology of SSRIs in elderly patients and on practical issues related to using these medications.

The Plight of Caring for Young Patients With Frontotemporal Dementia

We present the case of a 39-year-old patient with frontotemporal dementia. This case depicts the complexities in the process leading to the diagnosis, treatment, and placement of young patients presenting with severe psychiatric symptoms as the first signs of an underlying neurological disease. Obstacles in the health care system and residential placement process that hinder the optimal and timely care of such difficult cases are discussed. Practical solutions are offered that center upon better awareness and education and the provision of additional resources. These interventions are likely to provide a positive return on investment for the medical system and could be used as strong levers for new health policies relevant to younger patients with neurological illness.

Clinical and Neurophysiologic Characteristics of Unprovoked Seizures in Patients Diagnosed With Dementia

Seizures are a common comorbid condition in patients with dementia, but their characteristics have been poorly described. The authors performed a retrospective chart review using ICD-9 diagnosis codes consistent with seizures and with dementia. Seventy-seven patients were identified. Average age at onset was 68.1 years for cognitive symptoms, 71.5 years for dementia, and 73.9 years for seizures. Seizures preceded or followed cognitive symptoms (4.3 years before and 18.7 years after). At last follow-up, 12% of patients continued to have seizures. Findings show that unprovoked seizures can precede or follow the onset of dementia, but these seizures are controlled with medications in the majority of patients.

Diagnosing early onset dementia and then what? A frustrating system of aftercare resources.

Recent studies indicate that the prevalence of early onset dementia (EOD) is more common than it was once presumed. As such, and considering the substantial challenges EOD presents to the patient, caregivers, and health care providers, this study sought to investigate the mechanism of care delivered to these patients. A medical record chart review was conducted for 85 patients attending a memory disorder unit who initially presented to rule out EOD as a working diagnosis. The results suggest that while the majority of these patients received an extensive work-up and were heavily medicated, they remained at home, where they lacked adequate age-related services and could not be placed, despite the crippling caregiver burden. This manuscript is a platform to discuss our current system limitations in the care of these patients with an eye on new opportunities for this challenging group.

Restless legs syndrome: a review.

Restless legs syndrome (RLS) is a sensorimotor disorder characterized by an irresistible urge to move the limbs accompanied by uncomfortable sensations, leading to sleep disturbances. It is associated with psychiatric comorbidities and a decreased quality of life. RLS is common and most severe among females and the elderly. It may be primary or secondary to other conditions and may be familial. Linkage to several chromosomal loci have been demonstrated. The pathogenesis of RLS involves dopaminergic dysfunction, iron metabolism, and abnormalities in supraspinal inhibition. The mainstay of RLS therapy are dopamine agonists or levodopa. This article reviews the clinical characteristics, epidemiology, diagnosis, pathogenesis, and treatment of RLS.