Author: Dr Justin Marley

The podcast reviewed here is the Mind Podcast. In episode 9 Hoeve looks at hearing. This is a brief episode in which Hoeve introduces the reader to the auditory system covering the basic anatomy and physiology as well as looking at conductive and sensorineural deafness. In terms of the physiology he discusses the theories of neural coding of auditory information according to the position of the nerve cells as well as their firing frequency. In episode 10, Hoeve looks at taste and smell. He suggests that by listening to a large number of podcasts on psychology the listener can become a psychologist but I suspect that this is his sense of humour which would be in keeping with his relaxed style. This is a very brief episode and there is a focus on a few interesting findings about each – the adaptation of taste, the number of taste receptors, gender differences in sensitivity to certain smells and the effect of solutions on subsequent experience of ‘neutral’ taste stimuli. Again Hoeve provides a basic and very relaxed introduction to the material. I think for more advance listeners it can be useful to go over some of the basic concepts again as there is always scope for reinterpreting the basics after having assimilated more advanced knowledge depending on the listener’s needs.

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The book reviewed here is ‘The Meaning of Life: A Very Short Introduction (Unabridged)’ by Terry Eagleton and narrated by Jan Snyder. Firstly the narrator’s voice has a rich timbre and he speaks slowly, clearly and is able to maintain the listener’s interest throughout. Eagleton’s choice of subject, the meaning of life, is a big subject and one which has impacted on certain forms of psychotherapy. While I might have missed this, my experience of listening to the audiobook several times was that it was difficult for me to understand the overall structure of the book. Broadly speaking Eagleton tackles the definitions of meaning and of life in order to better frame the question of the meaning of life. He introduces the reader to notable philosophers who have commented on the topics he is discussing such as Camus, Sartre, Wittgenstein and Russell. Having no training in philosophy and only a little background knowledge, I found that certain points were covered too quickly and assumed a certain knowledge of the reader as in the meaning of postmodernism. My experiences of the book differed markedly throughout. In some parts there were references to meaning in popular culture and I thought that some of the points had been much discussed in this forum. In other parts Eagleton argues cogently about meaning. What I found quite powerful was not the rational arguments but rather the experiences that they evoked. This caused me to speculate that philosophy doesn’t necessarily have to be about rational arguments as much as about using the stream of consciousness to identify valid truths in a way which can be reproduced by others. At the same time, I suspect that this suggestion has probably been discussed before  and who knows – even debunked. That is the difficulty of reading about a familiar subject which is being explored using an unfamiliar discipline but is balanced by the new insights that can be brought to bear on an understanding of that subject. Another suggestion by Eagleton is that our lives are imbued with meaning whether we agree or disagree with meaning itself. We are thus born into a world of meaning constructed by others.

There was one part which I disagreed with and that is his brief discussion of happiness and disability. I disagre with his assertion that disability must impact on happiness. Here the answer is to go on and speak to people with disabilities and find out what their experiences of happiness or satisfaction is. Various people have already done this and found that the relationship between disability and satisfaction with life is a complex one that is dependent on many factors (e.g. (van Campen and Cardol, 2009)). There are numerous examples of people with significant disabilities living fulfilling lives and indeed challenging prejudices in society has been important in this regards. This also shows the importance of evidence in challenging prejudices and the risks associated with reasoning dissociated from empiricism (at least as stated in this case). While Eagleton doesn’t draw any firm conclusions about meaning he does move towards the values of agape and happiness as reasonable values of choice and here I thought that this fitted with positive psychology (see reviews here and here).

In conclusion, Eagleton tackles a difficult question from multiple perspectives giving insights from philosophy and although there were a few points on which I had disagreements with Eagleton as above, I found this a useful starting point for further reading.

References

Terry Eagleton. The Meaning of Life: A Very Short Introduction (Unabridged). Narrated by Jan Snyder. Audible Inc. 2009.

van Campen C and Cardol M. When work and satisfaction with life do not go hand in hand: health barriers and personal resources in the participation of people with chronic physical disabilities. Soc Sci Med. 69(1). 56-60. 2009.

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The paper reviewed here is ‘Mental Health Services in Mexico’ by Berenzon and colleagues. This is a concise article which runs to just over 2 pages but which gives a useful overview of the subject. The authors describe the structure of health services in general which are broadly divided into three categories – those funded by social security for employees, private service providers for those able to afford it and provision for the poorest members of the population funded by the popular insurance scheme. Within this context, the mental health services operate and follow mental health policy and legislation from 1983 followed by a Mental Health Program of Action initiated i in 2001 and a National Health Programme that commenced in 2007. The article continues with a look at the resources in Mental Health Services, the organisation of these services, training in psychiatry, research and a look at future challenges. There were two items in the article that I found of particular interest. The first was a breakdown of resources sourced from the WHO  – 44 psychologists (presumably in mental health) per 100,000 of the population compared to 2.8 psychiatrists per 100,000 of the population. The authors have included a table that allows comparison with other countries in the Americas including the USA and Cuba both of which have substantially more psychiatrists and psychiatric beds per 100,000 of the population. The other point I found quite interesting was that in rural areas there is limited access to the psychiatrist and people may instead consult ‘traditional doctors and informal agents’. Discrepancies between rural and urban mental health care extend to other countries where solutions such as telehealthcare have been adopted in an effort to utilise limited resources more efficiently. The authors note the relative concentration of mental health resources in Mexico City. After reflecting on this, I thought it would be interesting to see what relationship exists between the size of a city and the proportion of a country’s mental health resources that are accessed by the same city. So for instance, is there a linear relationship between the proportion of mental health services and the proportion of the population contained within a city or is there a non-linear relationship (e.g quadratic). In practical terms, if the population density is higher then there might be less far for both parties to travel to the consultation which in turn might impact on DNA rates. On the other hand, patients might live further away from the consultation centres or it might take longer to travel to the centres meaning that this question would benefit from an analysis of the relevant data. Similarly could such issues impact on the type of research that is carried out in different locations. These types of questions could be important. For example if we wanted to compare services between countries, would we need to compare urban centres against urban centres and rural centres likewise against their counterparts in the country of interest.

The authors have written a concise article which raises a number of questions and allow for a relatively rapid (but limited) qualitative comparison of services between countries.

References

Berenzon, S, Senties H and Medina-Mora E. Mental health services in Mexico. International Psychiatry. Vol 6. Number 4. October 2009. pp93-95.

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The paper reviewed here is ‘The Anterior Temporal Lobes and the Functional Architecture of Semantic Memory’ by Simmons and Martin. The authors review the evidence for three competing theories of the role of the Anterior Temporal Lobes (ATL) in semantic memory. There is no stated methodology for this review article but instead it appears to represent a review of the literature guided by the expertise of the authors in this area. This topic is potentially important for diseases such as semantic dementia. In the introduction, the authors outline three competing theories for the function of the ATL’s in semantic memory

1. The ATL links together areas in the brain containing semantic information

2.The ATL contains information about unique objects

3. The ATL stores ’social conceptual information’

They then go on to explain some of the subtleties within these classifications including the neat idea that the temporal lobe might not actually store the information itself but could point to this information elsewhere – in effect acting as a signpost. They alos highlight the possible roles for the ATL’s in storing broad or narrow categories of objects and specific objects or broader categories of objects.

The authors then go onto look at the some of the neuropsychological evidence for the role of the ATM in semantic memory. They comment on studies with transcranial magnetic stimulation in which the lateral surface of the ATL is targetted and where there is an impairment in object naming response. However they note that the TMS can have effects areas other than those directly targetted and so it is difficult to confirm a simple causal relationship between the two. There are similar arguments with other types of study and they also outline some of the counterarguments that have been developed.

The authors then look at neuroimaging data particularly fMRI studies. There is a focus on the conclusions of these studies rather than the methodologies and so this would be a useful starting point for further reading. The results cited included

– ATL activation on viewing familiar faces

– ATL activation on viewing famous faces

– ATL activation on inferring mental states and emotions in others

– Right ATL activated on ‘viewing photgraphs depicting scens with moral connotations…versus nonmoral control scens’

– Right ATL activated in relation to ’socal abstract concepts such as courage or generosity’

as well as a number of other findings. They comment that there are no direct comparisons of all three competing theories in a single neuroimaging study. In their conclusions, the authors suggest that comparisons of the different theories could be tested within the same study and also comment on the possibility of using alternative methodologies to test the theories. One suggestion which I thought was particularly interesting was the use of cortical surface recording. This has already proved useful in investigating the role of the speech and language areas and perhaps it might be useful in asnwering these types of questions.

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The paper reviewed here is ‘Psychiatric Presentation of Hashimoto’s Encephalopathy’ by Baca-Garcia and colleagues and freely available here. The authors describe the case of a Venezuelan lady who presents to the A&E department at Sao Joao hospital (which is in Portugal and I think has a website here). The team were aware that this lady had a previous history of treated hypothyroidism as well as three prior brief psychotic episodes treated with antipsychotics. She had presented with disorientation, paranoid delusions as well as delta waves on the EEG. The T3 levels were decreased and an antibody screen was undertaken which revealed elevated antithyroglobulin antibodies (Thyroglobulin is a precursor of T3). The researchers found reduced perfusion in the frontal, left temporoparietal and left posterior parietal regions on the SPECT (see the Corepsych blog reviewed here for further discussion on the SPECT). A diagnosis of Hashimoto’s encephalopathy was made and treatment initiated with intravenous methylprednisolone and oral prednisolone with improvement in antibody titres, EEG and psychiatric presentation within a few months. It would have been interesting to see if there were any changes on the SPECT. There were two things the authors wrote which were of interest. The first was speculation on parallels between acute disseminated encephalomyelitis and Hashimoto’s encephalopathy. The second was speculation on the pathological basis of the encephalopathy which they suggested as

1. Vasculitis

2. Direct toxic effects of thyrotropin releasing hormone

3. Local cerebral oedema

The interesting question here is why is the perfusion reduced on the SPECT? If this was repeated and the perfusion had improved in the aforementioned areas then it would be slightly easier to conclude that the perfusion abnormalities were directly related to the pathology. Speculating a little further, if the two are directly related, then it could be argued that a vasculitis would influence perfusion directly as might oedema. Interestingly the authors of another study looking at the neuropsychiatric manifestations of SLE concluded that a combination of MRI and SPECT was better at discriminating neuropsychiatric involvement from non-involvement in SLE on the basis of the imaging findings alone (Castellino et al, 2008). The authors present a rare but important cause of psychosis associated with thyroid pathology.

Castellino G, Padovan M, Bortoluzzi A, Borrelli M, Feggi L, Caniatti ML, TrottaF, Govoni M. Rheumatology (Oxford). 2008 Mar;47(3):319-23. Epub 2008 Jan 24. Single photon emission computed tomography and magnetic resonance imagingevaluation in SLE patients with and without neuropsychiatric involvement.

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News in Brief

In the British Journal of Psychiatry, there is a systematic review of pharmacotherapy for Borderline Personality Disorder (Lieb et al, 2010). The researchers identified pharmacotherapy studies of people with a DSM-III/DSM-IIIR/DSM-IV/DSM-IV-TR diagnosis of Borderline Personality Disorder. They included studies which allowed for pooling of effect sizes and grouped the symptom clusters into interpersonal problems, impulsive-behavioural dyscontrol, cognitive-perceptual symptoms and affective dysregulation. In these four clusters, the researchers were able to find clinically and statistically significant effects for specific psychotropic medications which are outlined in the article. They note a number of limitations including the exclusion criteria in the original studies meaning that in a number of studies there may be differences from a clinical sample of people with a diagnosis of Borderline Personality Disorder. They conclude from their study that on the basis of their evidence pharmacotherapy can be directed at symptom clusters and they suggest that their findings can be of relevance to any revisions of APA and NICE guidelines.

In a small, preliminary study (n=9) looking at the use of blueberry juice on memory there was a significant improvement on a test of paired associative learning and word list recall at 12-weeks in older adults with ‘early memory changes’. However this will need to be replicated preferably over a longer time period and in a well characterised and larger population with randomisation, blinding and a control group. While blueberries are noted to have strong antioxidant properties, the authors suggest that it is the properties of the anthocyanins in blueberries which influences neuronal signalling which may relate to any beneficial effects.

The researchers in a study using Magnetoencephalography looked at a group of US Veterans with Post-Traumatic Stress Disorder (PTSD)(n=74) and a group of controls without PTSD. They identified a characteristic signal in the people with PTSD using what they refer to as the ’synchronous neural interactions test’. The distinction between this biological marker and a diagnosis of PTSD is discussed over at MindHacks.

A development in electron microscopy is the use of electron cryotomography. This is the rapid freezing of biological materials to -140 degrees Celsius to preserve the positions of intracellular structures. This article looks at a study published in the Journal of Cell Biology using this technique. The authors note that filaments in the neuron constrain the activity of intracellular vesicles which contain neurotransmitters for release for example.

This article looks at a study which investigated the effects of other people with varying degrees of self-control on a person’s own self-control in a variety of experimental scenarios. In these scenarios the researchers found evidence that finding evidence of self-control in others or thinking of those with ‘high’ self-control was associated with a higher degree of self-control in the subject.

News Round-Ups

MindHacks has another episode of Spike Activity which includes links to an article on a research study looking at the use of diagnostic terminology on perceptions of management approaches and a twin study in face-recognition (as well as some robophobia for good measure).

Psychiatry 2.0

Over at Psychotherapy Brown Bag there is a very interesting article on the relationship between experience and efficacy in psychotherapy. Professor Dunbar, who coined the Dunbar number has been looking at Facebook relationships. The Dunbar number – 150 – indicates roughly how many relationships people can manage effectively. Professor Dunbar followed up his earlier work by looking at Facebook and has suggested on the basis of his analysis that there is evidence that this number remains. Even when people have higher numbers of friends, they effectively manage the core group of about 150. He also found some gender differences in relationship maintenance.

Evolutionary Psychiatry

While not directly related to humans, this news article involves an interview with a researcher and looks at the ‘evolution’ of stray dogs in russia. The dogs have to adapt to urban conditions. It does raise the question of how much urbanisation impacts on evolution although the selective pressures on dogs will be significantly different from people in these environments (it was interesting to see that the dogs have learnt to ride on the underground!). A mathematical model has been constructed to investigate the coevolution of the hands and feet in humans basing some of the assumptions on measurements in the humans and chimpanzees. The model supports the hypothesis that changes in the feet could affect the shape of the hands (and vice versa) and is interesting in view of the recent publication of the Ardi find (the authors of the Ardi publications took 17 years to prepare the material before publication!) a distant human ancestor which moved through the trees as well as walking upright.

References

Lieb K et al. Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials. The British Journal of Psychiatry. 2010. 196. 4-12.

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The podcasts reviewed here are two episodes in the series of the Mind Podcast. The podcaster Hoeves provides another good introduction in the 7th episode and this time looks at vision. He gives an overview of the wavelengths of visible light before turning to the basic anatomy of the eye and briefly covers the transmission of signals through the retina and into the visual cortex. He uses other terms for structures commonly referred to as the Optic Chiasm and the Lateral Geniculate Nucleus but otherwise his relaxed approach and background music provide the listener with a pleasant and basic introduction to the subject of vision. In the 8th episode, Hoeves looks at the physiology of the visual apparatus covering the principles of dark adaptation, lateral inhibition as well as colour blindness. Again Hoeves provides a basic introduction to the subject and does so in an engaging style.

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The blog reviewed here is ‘Science in the Open’ which can be found here.

Appearance and Design

There is a striped cyan background with a central white background for the articles and the side-pane. The title pane consists of a background of interlocked green and blue arms – most likely an analogy to the nature of the open science. On the right-hand pane, there are links to recent posts and recent comments as well as an RSS feed, an About section. The blog content is also marked as Creative Commons, which is in keeping with the spirit of an open science collaborative. The blog must be navigated by moving to the foot of the page and clicking back on older entries on each successive page.

Content

Here are a few of the articles I found interesting. The first article is dated August 13th 2007 and looks at what terms such as Open Access means:-

‘Open Access (of journals, data, or anything else really): Means freely available and accesible to use, re-use, re-distribute, re-mix subject only to a requirement to attribute the work. Essentially as described in the Berlin and Bethesda declarations’

Some current policies on open science are covered in this post.and further developments are discussed in this post. In this post, there is a call for open science collaboration on a chemistry experiment and I thought there was an interesting comment here about the concerns of valuable data being released in an open source environment. Concerns such as these will have to be addressed in making open science a successful reality. There is an interesting post here on open science in the developing countries. New ways of doing science are discussed in this post and the dangers of communities reinforcing their prejudices and thus interfering with a progress towards an open science are discussed here. Notes from a conference – Scifoo on open science were interesting. New technologies are covered including Google Wave and a focus on the Wave Robot here.

Conclusions

This blog about open-science is filled with insights and the posts are intelligently written and original. A number of the posts are very technical involving chemistry, specific software or some knowledge of computer programming. However these are balanced with the other articles giving a broader perspective on Open Science. The reader with an interest in the future of science in the 21st century would benefit from paying close attention to this blog and it compliments other blogs reviewed here (e.g see this review).

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The paper reviewed here is ‘Physical activity and risk of neurodegenerative disease: a systematic review of prospective evidence’ by Hamer and Chida. This is an important subject given the impending epidemic of dementia that is being predicted. The underlying question is obvious – can exercise reduce our risk of dementia?

The researchers undertake a meta-analysis of epidemiological studies investigating the relationship between risk of dementia and physical activity according to a previously identified protocol for ‘reporting meta-analysis of observational studies in epidemiology’ by Stroup and colleagues in 2000. They identify three databases (1990-2007) for their initial search

(1) Medline

(2) The Cochrane Database of Systematic Reviews

(3) The Web of Science Databases

They used the terms ‘physical activity’ or ‘exercise’ and ‘Alzheimer’s Disease’, ‘Parkinson’s Disease’ and ‘Cognition’. I thought it might have been useful to add ‘Vascular Dementia’ to the search particularly as this is a relatively common form of dementia and can occur comorbidly with Alzheimer’s Disease. It would have been interesting to see other forms of dementia including Frontotemporal Dementia. However the terms can be justified on the basis that the results are presented according to the subtypes as well as the broader umbrella of ‘dementia’.

After the initial filtering of papers according to the inclusion criteria (e.g english-language papers, prospective cohort studies), the researchers rated papers independently according to quality (e.g quality of outcome measures used) and validity. The studies of interest included the Hazards Ratio and/or Relative Risk ratios for dementia according to level of physical activity.

They identified 1866 studies and included 16 in the final analysis. I wasn’t clear on whether the physical activity levels were comparable between the subjects in the studies. The papers included organised physical activity into groupings and the researchers then selected out a comparison of the highest physical activity group against the lowest physical activity group.

The pooled relative risk ratio for Alzheimer’s Disease in the highest v lowest physical activity groups was 0.55 with a 95% Confidence Interval of 0.36-0.84 (p=0.006) although they found significant heterogeneity in these results. They were unable to find publication biases (using the Begg’s asymmetry method) in the analyses. They identified more ‘robust’ effects in the ‘higher quality’ studies compared to the ‘lower quality’ studies. They concluded that high levels of physical activity could reduce the risk of Alzheimer’s Disease by45% on the basis of these findings.

With an analysis of the epidemiological data here, there remains the question of whether there could be confounders. One confounder might be the comorbidity of Vascular Dementia with Alzheimer’s Disease particularly as the physical activity will be expected to impact on cardiovascular health. A more recent confounder however is quite surprising – sitting! This study has only just been covered in the media (e.g here and here) so I haven’t had a chance to see the original paper (which I couldn’t find on the site yet). Perhaps this would be an area for further study.

References

Hamer M and Chida Y. Physical activity and risk of neurodegenerative disease: a systematic review of prospective evidence. Psychological Medicine. 2009. 39. 3-11.

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The audiobook reviewed here is ‘The Brain: A Very Short Introduction (Unabridged)’ by Michael O’Shea (who I think is Professor Michael O’Shea who has a webpage here –  I couldn’t identify biographical details on the audiobook).

O’Shea starts by describing the work of Galen and the suggested impact of the humours on the body – a model which endured until the seventeenth century before moving onto later models developed. He also looks at some of the landmark events such as the discovery of electrical conduction in the nervous system as well as the structure of the neurons. O’Shea then looks briefly at the evolution of the nervous system explaining some of the consequences of symmetrical body plans on the evolution of the nervous system. He also covers embryological development very briefly and then neuroanatomical structures with a description of the known functions of these structures. I thought this was one difficulty with the audiobook – that it refers to structures which should ideally be visualised particularly in the case of a general audience. A visual aid is obviously difficult for an audiobook and so either it is assumed that the reader is familiar with the structures previously or will access visual aids to help them better understand the material in the book. The author then goes onto discuss cellular physiology and the influence of axonal diameter on conduction velocity and the leakage of current in a salty fluid. He also discuss the work of some of the scientists involved in neurophysiology.

He then looks at the evolution of the hominid brain examining the changes in brain size that have occurred in the transition across species. O’Shea also considers the role that neural prosthetics could play, reviewing some of the research in this area. To introduce the brain in the relatively short space of 4 hours is a difficult feat and O’Shea does a nice job, taking the reader through some of the principles of neurophysiology, neuroanatomy and evolutionary development while drawing attention to some of the prominent figures in neuroscience research and their works. He also highlights some points with a description of the relevant studies. This introduction to the brain is an engaging look at robust conclusions about the brain and its functions and some of the research that has led to these conclusions.

References

Michael O’Shea. The Brain: A Very Short Introduction (Unabridged). Narrated by Dennis Holland. Audible inc. 2009.

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The paper reviewed here is ‘Social Cognition Skills Training in Schizophrenia’ by Horan and colleagues. In this  study, the authors are looking to see if a new social cognition skills training program that they have developed is effective at improving social cognition. They begin with a brief observation that while symptom control in schizophrenia has been effective this is not necessarily linked to functioning. They discuss the term social cognition very briefly in the introduction. I find this concept quite complex and it is probably in a state of flux at the moment. They then look at some of the evidence suggesting that there can be difficulties with social cognition in schizophrenia and then summarise some of the research into methods that improve social cognition in people with schizophrenia. Such approaches include the Training in Affect Recognition program and Social Cognitive and Interaction Training (SCIT). The researchers observe that in a number of studies in the area of social cognition skills training in schizophrenia there were no control groups, it was not clear if the changes in skills resulted from a confounding improvement in general cognition and also the studies had not looked at inpatients.

In this study, the researchers conducted a 6-week trial with 34 participants. Subjects met the DSM-IV criteria for schizophrenia or schizoaffective disorder and were recruited from a healthcare centre in Los Angeles. 60% of the subjects in the social cognition group were African-American and 27% caucausian while 50% of the subjects in the control group were African-American and 31% caucasian. 26 of the subjects were taking atypical antipsychotics (not in combination with typicals). The control group underwent an ‘illness self-management and relapse prevention skills training’ program. They give a broad overview of the control program which includes a ‘fully manualised training program’ with videos and scripted exercises that focus on 4 areas which include identification of relapse warning signs.

The intervention consisted of ‘two 6-session phases’ which covered

(a) ‘Emotional and social perception’.

(b) ‘Social attribution and Theory of Mind’.

In the first phase, the subjects underwent training to identify ‘basic emotions on the face and in the voice’ borrowing from established programs and using ‘computerised facial affect perception training exercises.. and facial mimicry exercises’. Training continued with ’social cue perception skills and social context appreciation’. This involved recognition of social norms and non-verbal gestures.

In the second phase, paranoia was considered as an emotion and the subjects were trained to distinguish between ‘useful’ suspicion and ‘harmful’ suspicion, between facts and guesses and checking out beliefs with the evidence.

The four social cognition outcome measures were

(a) The Facial Emotion Identification Test

(b) The Half-Profile of Nonverbal Sensitivity (PONS)

(c) The Ambiguous Intentions Hostility Questionnaire (AIHQ)

(d) The Awareness of Social Inference Test (TASIT)

I couldn’t see the details on the validity and reliability for each of the above although the researchers have cited the original papers.

Cognition was assessed using the MATRICS Consensus Cognitive Battery (MCCB).

The researchers use the ANCOVA for the primary outcome measures which consist of the differences in the cognition and social cognition measures between the two groups.  Essentially there was a significant between group effect only for the facial affect perception. What this meant was that on this measure the social cognition skills training group improved significantly more than the control group. A ‘moderate to large effect’ was noted in the social cognition skills training group. There wasn’t a significant difference between the groups on the MATRICS.

I thought this was an interesting study. This is a relatively short trial at 6-weeks and it would be interesting to see if the effects are sustained and if they are replicated in a larger group given the promising initial results.

References

Horan W P, Kern R S, Shokat-Fadai K, Sergi M J, Wynn J K and Green M F. Social cognitive skills training in schizophrenia:An initial efficacy study of stabilized outpatients. Schizophrenia Research. 107. 2009. 47-54.

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The article reviewed here is ‘Catatonia. Treatment and Recognition’ by  Cottencin and colleagues. This is a paper consisting of a case report with discussion. The authors describe the case of a 54-year old lady with a history of hypomania (later revised to Bipolar Disorder) who was initially admitted to hospital for an alcohol detoxification. After being noted to have depression with anxiety she was then discharged on an antidepressant as well as an antipsychotic with sedative properties – Cyamemazine which acts at D2 and serotonin 2c receptors.  She was readmitted 2 days later with a number of symptoms including mutism, disorientation, flight of ideas, wandering, rigidity and oppositionalism. The authors included Neuroleptic Malignant Syndrome as a differential but there is no mention that I could find of the CK’s or autonomic features. The authors focus on their main differential that of catatonia. They found that she scored highly on the Catatonia Rating Scale (although commenting on the reliability and sensitivity of catatonia scales) and then proceeded to initiate a Zolpidem challenge. She responded well to this and there was a marked improvement on the Rating scale scores which peaked at 45 minutes before returning to (roughly) baseline levels after 3 hours. The authors conclude that a Zolpidem challenge is a useful confirmation test for catatonia before speculating that the withdrawal from a number of GABAergic medications prior to the episode may be related to the onset of the catatonia. The difficulty in interpreting a case-report is that it is difficult to control for a number of potentially important factors – medications, mood, alcohol withdrawal, abrupt withdrawal of multiple medications to name but a few. The opportunistic case-report also differs from the more ‘controlled’ settings of the clinical trial where subjects with certain characteristics are selected for inclusion. Nevertheless they offer initial evidence and the speculation here has led to a useful hypothesis which can be further assessed.  

 

References

Cottencin O, Danel T, Goudemand M, Thomas P and Consoli S. Catatonia recognition and treatment. Med Sci Monit. 15(8). CS 129-131.  2009. 

 

 

 

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In the earthquake tragedy in Haiti, social media is being used to aid donations as well as to get information out to the rest of the world. This is covered in this article here. Professor Richard Williams, is interviewed in this article and discusses some of the effects that the earthquake might have on children in Haiti and approaches to responding to this.

A recent study that has attracted media interest is a murine study suggesting that looking at nerve cell death in the retina can be used to predict Alzheimer’s Disease. This is covered in more detail at the NHS Choices site where it is noted that human trials are awaited before such conclusions can be drawn. Several studies providing evidence of an association between amyloid protein-induced damage to the microtubule system in human and murine cells and Down’s Syndrome, Alzheimer’s Disease and atherosclerosis. It will be interesting to see further supporting in-vivo studies.

The Psychiatric Bulletin familiar to British Psychiatrists has been renamed ‘The Psychiatrist’ and includes articles submitted by allied mental health professionals. There are 2 interesting articles on the recovery model as well as a meta-analysis of low and high-dose quetiapine. The latter article looks includes two studies (combined n=175) and concludes from the evidence that low and high dose quetiapine show equal efficacy in schizophrenia on outcome measures including positive symptom score on the Brief Psychiatric Rating Scale although these were 6-week trials  (Painuly, 2010). There is another interesting article by a nurse and psychologist team reviewing the standard community mental healthcare for people with severe personality disorder. The researchers were interested in the standard management against which other treatments were compared and conclude by recommending further empirical evidence for the standard approach (Koekkoek et al, 2010).

Round-Ups

MindHacks has another good round-up of the news and links to a number of articles including a novel drug with anxiolytic properties. Mental Nurse have another round-up of blog articles including a look at Frontier Psychiatrist’s article on antidepressant use in dogs. The grand rounds includes a link to the Dr Shock article on virtual reality therapy for PTSD.

Evolutionary Psychiatry

A recent finding has been the interpretation of a 50,000 year-old Neanderthal clam shall which contains remnants of yellow and red pigmentation together with a black mineral substance. The researchers have concluded that this pigmentation was being used as make-up. Since humans did not arrive in Europe till much later, it was concluded that this is evidence of a Neanderthal culture and this adds to other evidence about Neanderthal intelligence (see here also). This also raises possible questions about the transformation of human art on entering Europe. The most interesting question however is whether Neanderthals are part of our genetic heritage and that question will hopefully be answered with the sequencing of specimens of the Neanderthal genome. The recent sequencing of the Chimpanzee y chromosome suggests that chimpanzees have between one-third and one-half of the genes in the human genome and that the y chromsome has undergone rapid changes relative to the other chromosomes which have been sequenced in both humans and chimpanzees. This should have implications for the kind of inferences we can draw.

References

Koekkoek B, van Meijel B and Hutschemaekers G. Community Mental Healthcare for people with severe personality disorder: narrative review. The Psychiatrist. Review Article. 34. 24-30.

Painuly N. High v low-dose quetiapine in schizophrenia: meta-analysis. The Psychiatrist. 2010. 34. 9-12.

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This is a new feature. Meditations are a form of expression, an exploration of a subject using introspection. They fall outside of the domains of philosophy and science. This first meditation is on meditations themselves. Their purpose is to use introspection to investigate a subject in contrast to the rigorous methods used in science and philosophy. They have no authority and any conclusions drawn are at the best speculation. Responses are welcome.

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In support of Method is now available as a video split into 11 parts which can be accessed below.

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The podcast reviewed here is the Mind Podcast. In the 4th podcast in the series which is part 1 of 2 about the brain (available here) Hoeve gives an overview of the brain with a brief discussion of anatomical structures, very brief functions for different parts of the brain and imaging studies that are used to investigate brain function. He also covers the case of H.M who developed anterograde amnesia after a bilateral temporal lobectomy. Hoeve has noted in a previous episode of the podcast series that he has created these podcasts as he is studying and I think these podcasts are a useful starting point for further reading giving orientation to the field. His podcasts are specifically aimed at those studying psychology. I thought that a neat feature of the podcasts was the Baroque music playing in the background although there are some listeners who prefer to separate background music from educational material. In part 2 of the series about the brain (available here) he has interestingly created an accompanying mindmap to represent the information. He gives a broad overview of the structure of the cerebral cortex with some accompanying functions for each area including the sensory and motor homunculi as well as Broca’s area In the third part of the series (available here) he has a basic overview of the endocrine system. Melatonin is replaced with melanin and I thought there was a slightly different pronunciation of the Pineal gland. He also discusses genetics towards the end of the podcast. Again this is relatively brief introductory material that is useful for those new to this area. Hoeve has an easygoing manner and creates some pleasant introductory material.

Other reviews of the Mind Podcast

Episodes 1-3 reviewed here

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I’ve just completed the second installment of a film on the events surrounding a paper by Ed Vul and colleagues from 2008/2009. There were a number of issues that this debate picked up including technical issues in the field but it also offers a useful focal point for discussion a lot of connected areas particularly in what is referred to as Science 2.0 – the potential open collaborative effort that is offered by the medium of the internet and the internet community.

Addendum

New Scientist article citing Vul et al paper and examining link between ‘consciousness’ and neural activity

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Here are some of the research studies from 2009 that I thought most interesting:-

1. The paper that I found most interesting was Vul and colleagues paper on ‘Puzzlingly High Correlations in fMRI Studies of Emotion, Personality, and Social Cognition’. The paper was reviewed in its original format here. I’ve also made a short film about the paper.

2. The discovery of a new ancestor Ardipithecus Ramidus published in Science

3.  The discovery of three strong gene candidates (CLU, PICALM and CR1) in Alzheimer’s Disease published in two papers in Nature

4. A case-control study in Nature looking at copy number variants in Schizophrenia

5. The DART-AD study which examined some of the possible risks associated with antipsychotics in dementia

6. A further study examining the possibly complex relationship between ACE inhibitors and dementia

7. A meta-analysis of psychological tests that discriminate vascular dementia from Alzheimer’s Disease

8. A 5-minute cognitive screening tool for Alzheimer’s Disease

9. Methylene blue does it again, this time with optic neuropathy (Rojas et al, 2009) – well in a model of optic neuropathy

10. (Lowenstein et al, 2009) find that cases of Mild Cognitive Impairment are more likely to revert if the diagnosis is made on the basis of a single assessment

11. A retrospective case series of Frontotemporal Dementia in relation to adult-onset illnesses (Velakoulis et al, 2009)

12.  A New York prospective study showing the benefits of a Mediterranean diet and exercise in reducing prevalence of dementia

13. A prospective study showing the benefits of antihypertensive medication on cognitive decline

14. A 32-year prospective study showing an association betwen central adiposity (and not BMI) in women and subsequent development of dementia

15. A 9-year prospective study showing the benefits of exercise on reducing stroke risk

16. An association between extra-curricular activities at school and later further education

17. A high prevalence of neuropsychiatric complications of SLE

18. The finding that of those genes identified 3000 were differentially activated over a 24-hour period

19. A Cochrane review showing the benefits of a computer feedback program for Alcohol Misuse in college students

20. The benefits of media-resistance skills programs on teenagers on alcohol consumption

21. The revival of a cloned extinct species

22. The benefits of dialectical boot-strapping in decision making

23. Naltrexone in kleptomania

24. Sleeping less than 7 hours or more than 8 hours a day was associated with a 2-fold increased prevalence of type II diabetes in this study

25. A computer-robotic scientist for performing yeast science

26. An american cohort of older adults performed as well on cognitive tasks as their british cohorts 10 years their junior with explanations suggested

27. A large study showing an inverse relationship between fish consumption and prevalence of dementia

28. An American study finding that 1/3 of 3-6 year olds wanted to change some aspect of their appearance

29. Of 472 million psychotropic medications prescribed in America, only one quarter had been prescribed by psychiatrists

30. A recent study involved 1224 bloggers and found that the main principles which bloggers valued were ‘truth, accountability, minimising harm and attribution’. Hear, hear.

What does 2010 have in store?

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As this is the 150th anniversary of Charles Darwin’s publication of  ‘On the Origin of Species’, I’ve taken the opportunity to pay a small tribute both to Darwin and his important work. For the past year, in my spare time i’ve been filming primates in various locations. As evolutionary psychiatry is an emerging and potentially important area (see review here), I thought it useful to gain some insights. This is a work in progress and will be updated periodically.

Darwin himself wrote about parallels between humans and other species in his work on the emotional expressions of man. More importantly he noted in 1838

‘He who understands Baboons would do more to metaphysics than Locke‘

Primatology is an area with which I am not familiar and so I have approached this as an amateur. However through the process I have come to learn a little more about primates and developed both a respect and a fondness for these creatures. I have also begun to gain some potential insights which might be transferable to human psychology. Brune and others have outlined a broad theoretical underpinning for evolutionary psychiatry. The hypothetical behaviour of humans in recent history based on reconstruction of archaelogical findings poses the obvious difficulty that behavioural inferences are speculative. Nevertheless the study of primates offers the possibility that behaviours can be witnessed at first hand. The major difficulty with attempting to draw inferences about humans from these observations is that a considerable period of time has elapsed since our divergence from other primates. Take our nearest relatives, the chimpanzees. We have diverged some 6 million years ago. Within this period of time it would be surprising if the chimpanzee had not evolved considerably. This is supported by recent findings. The discovery of Astrolipithecus Ramadus suggests that Chimpanzee hands are more evolved than human hands since they have had more time to evolved. Furthermore experimental evidence suggests that Chimpanzee working memory is superior to humans which is demonstrated in this clip. The extreme time periods over which our species have diverged suggests that we can draw few reliable inferences on the basis of observations alone since we would then be assuming that the other species remains essentially unchanged since our divergence. Nevertheless once the sequencing of all primate genomes is complete and we have a better understanding of the genome differences, I would expect an iterative improvement in understanding the significance of behavioural similarities and differences. Thus I would predict that this field will move from being highly speculative to more realistic and supported by triangulation with data from other fields.

In the interim, I have captured the following footage which can also be accessed via the TAWOP channel on YouTube.

PROSIMIANS

Ruffed Lemur (Black and White)

Ring-Tailed Lemur

Brown Lemur

Black Lemur

Red Ruffed Lemur

NEW WORLD MONKEYS

Pigmy Marmoset

Silvery Marmoset

Golden Lion Tamarin

Golden Headed Lion Tamarin

Emperor Tamarin

Cotton Top Tamarin

Colombian Spider Monkey

Squirrel Monkey

OLD WORLD MONKEYS

Rhesus Macaque

Roloway Monkeys

Diana Monkey

HOMINOIDEA

Gibbon

Orang-Utan

Gorilla

Chimpanzee

Bonobo

Human-Like Behaviours

I have termed complex goal-oriented behaviours which resemble those seen in humans as human-like behaviours. The difficulty with drawing inferences about such similarities in complex behaviours are numerous. Nevertheless having a database of examples of such behaviours offers a starting point for further study. The existence of video sharing sites such as YouTube offers the possibility of rapid dissemination of such information as well as the possibility of establishing research networks.

Bonding Behaviour (Including Kissing-Like behaviours)

I was fortunate enough to have observed this Chimpanzee engaging in what superficially appears to be kissing. Examination of the footage on either side of this segment identifies that it is a continuation of the grooming behaviour that the Chimpanzee engages in both before and after. Nevertheless it does offer the speculative hypothesis that kissing exists in humans as a remnant of grooming behaviour in other primates. The significance of the loss of grooming behaviour in humans has also been considered elsewhere (see review here).

Pets

This clip of a gibbon is one of the most incredible pieces of primate footage I have seen. The gibbon is such a graceful mover but what is striking here is how this one gibbon has complete dominance from its higher position over several tiger cubs. Already we see what may be the rudiments of the ability to exhibit dominance over cats and by the end of the clip we see that the tiger cubs have moved out of the gibbon’s territory. Here we see another gibbon teasing a dog and again it’s quick reactions and use of a nearby tree mean that it has the advantage over the dog. There is other footage that I have observed which leads me to conclude that the gibbon engages in a strategy when it sees dogs or tigers that involves pulling the animal’s tail and then retreating quickly to the safety of a higher altitude which the dog or tiger cannot access. In one of the clips above, this seems to be done to protect the territory but in the other clip above it is unclear what the purpose of this behaviour is. The gibbon antagonises the dog and presumably removes itself rapidly from the scene in order to avoid the obvious consequences. However, if the gibbon did not engage in the initial behaviour it would have no cause to escape. Although the numerous clips of this behavioural strategy exist, this may constitute a selection bias which distorts the impression of the behaviour in these circumstances. Nevertheless there ought to be some explanation for these episodes and it is tempting to speculate that this may be an adaptation to the Gibbon’s environment where it  must adapt to dangerous predators in its native environment. If this is the case then it is either transmitted genetically or through observation of it’s parents or other group members.

Long Term Planning

This clip shows monkeys collecting and breaking nuts. They leave them for a certain period and return to complete the food preparation process. This entire process displays long-term planning as well as tool use.

Hunting

A BBC clip of a tarsier hunting. This is one of the earliest primates and can be seen here engaging in intricate hunting maneouvres.

Play

In this clip, a baby Chimpanzee appears to play with a Baboon although it may be more properly considered sparring. Two Gorillas are seen to be sparring in this clip. Their teeth are bared.

Theory of Mind

Although not a behaviour, I have grouped it here. This clip in my opinion displays that construct usually referred to as ‘theory of mind by a group of Chimpanzees. It is a most unfortunate clip as it results in the killing of other Chimpanzees and consequent cannabalism. Nevertheless in the build-up to this it is possible to see that the chimpanzees organise themselves as a group taking care to remain silent while lying in wait. It is difficult to know how this was achieved other than to suppose that the group had a shared understanding of what was to happen. How they knew to do this without a shared language suggests that they are able to communicate intent using a shared language and/or they had developed this strategy from hunting smaller primates where there is a lower risk from retaliation if there is a failed hunt.

Walking upright

These Bonobos are seen to walk upright. This Chimpanzee which is described as being in Uganda is seen to be walking upright through the grass.

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Biological Psychiatry Article Reviews

Voodoo Correlations in Social Neurosciences

Response to ‘Voodoo Correlations in Social Neuroscience’

The Paper Formerly Known as ‘Voodoo Correlations in Social Neuroscience’

Correlations in Social Neuroscience Aren’t Voodoo

Reply to Comments on ‘Puzzlingly High Correlations in fMRI Studies of Emotion, Personality and Social Cognition’

Correlations and Multiple Comparisons in Functional Imaging – A Statistical Perspective

Big Correlations in Little Studies

Discussion of Puzzlingly High Correlations in fMRI Studies of Emotion, Personality and Social Cognition

Understanding the Mind by Measuring the Brain

Review: Transfers to Psychiatry Through the Consultation-Liaison Psychiatry Service

Event-related potentials in the assessment of Mild Cognitive Impairment was reviewed

Aging and Synaptic Plasticity

APOE status and Association to Learning was reviewed here

Intranasal Administration of Acetylcholinesterase Inhibitors was reviewed

Genetics of Alzheimer’s Disease: Recent Advances

Subcortical Vascular Ischaemic Dementia

Metabolic Syndrome and Risk for Vascular Dementia

Review of the Seattle Protocols: Exercise Interventions for Dementia and Cognitive Impairment

Acetylcholinesterase Inhibitors for Vascular Dementia and Alzheimer’s Disease Combined with Cerebrovascular Disease

Effects of Rofecoxib or Naproxen vs Placebo on Alzheimer Disease Progression

Review of Anosmia in Lewy Body Dementia

Review of Frequent Amyloid Deposition without Significant Cognitive Impairment Among the Elderly

Recent Developments in Alzheimer’s Disease Therapeutics

SPECT, MRI and Cognitive Dysfunction in Multiple Sclerosis

Medical Progress – Treatable Dementias

Review: Preventing Dementia by 2020

Incidence and Prediction of Falls in Dementia. A Prospective Study in Older People

Neuroprotection for Huntington’s Disease. Ready, Set, Slow

The Ubiquitin-Proteasome Pathway in Huntington’s Disease

Review: Striosomes and Mood Dysfunction In Huntington’s Disease

Review: Beyond the Brain in Huntington’s Disease

Review: Frontal-Subcortical Dementias

Review: MRI Atrophy In Alzheimer’s Disease

Review: Delirium. Sifting Through the Confusion

Review: Clinical Decline and Education in Frontotemporal Lobar Degeneration

Review:Relationship Between 24-hour Blood Pressures, Subcortical Ischemic Lesions and Cognitive Impairment

Review:Autophagy in Neurodegeneration and Development

Review: The Genetics of Delirium

Review: Valproate and Neuroprotection

Neurobiological Mechanisms in Major Depressive Disorder was reviewed here

Review of Comparative Efficacy and Acceptability of 12 New-Generation Antidepressants

Medication Adherence and Admissions in Bipolar Disorder

Review: Symptoms, Neurocognition and Functional Outcome in Schizophrenia:A Meta-analysis

Review: Predicting Age-Specific Dosing of Antipsychotics Results of Phase III of the CATIE Schizophrenia Trial

How Do You Feel – Now? The Anterior Insula and Human Awareness

Social Concepts are Represented in the Superior Anterior Temporal Cortex

Review: The Genetic Basis of Human Brain Evolution

Psychology/Psychotherapy Article Reviews

Winnicott on fidgetiness

Winnicott on Appetite and Emotional Disorder

Winnicott on Ocular Psychoneuroses of Childhood

Winnicott on Reparation in Respect of Mother’s Organised Defence Against Depression

Winnicott on the Mind and its Relation to the Psyche-Soma

Winnicott on Anxiety Associated with Insecurity

Winnicott on Withdrawal and Regression

Winnicott on Primary Maternal Preoccupation

Winnicott on the Antisocial Tendency

Winnicott on Paediatrics and Childhood Neurosis

Winnicott on Metapsychological and Clinical Aspects of Regression

Winnicott on Transitional Objects and Transitional Phenomena

Winnicott on Symptom Tolerance in Paediatrics

Winnicott on A Case Managed at Home

Winnicott on Clinical Varieties of Transference

Winnicott on Primitive Emotional Development

Neuropsychological Deficits Associated with Alzheimer’s Disease in the Very Old. Discrepancies in Raw v Standardised Scores

Article on Cognitive Dysfunction in Multiple Sclerosis

Spatial navigation deficit in Amnestic Mild Cognitive Impairment was reviewed here

Frequency and course of Mild Cognitive Impairment in a Multiethnic Community was reviewed here

Mild Cognitive Impairment: Cognitive Screening or Neuropsychological Assessment was reviewed here

Anosognosia for Amnesia

Psychiatric Disturbances in CADASIL

Cognitive Decline in CADASIL

Impact of Frontal Systems Behavioural Functioning in Dementia on Caregiver Burden

Cognitive Impairment after Small Vessel Disease Associated Stroke

Familial Psychiatric Presentation of Huntington’s Disease

Psychopathology in Verified Huntington’s Disease Gene Carriers

Implicit and Explicit Aspects of Sequence Learning in Presymptomatic Huntington’s Disease

Cognitive Impairment in MS: Evidence-based analysis

Differential Cognitive Impairment for Diverse Forms of Multiple Sclerosis

Dissociable Deficits in Multiple Sclerosis

Neuropsychological Impairment in SLE: A Comparison with Multiple Sclerosis

Vascular Cognitive Impairment No Dementia (VCIND)

Comparison of Psychosomatic Outpatient Clinic with Community and Inpatient Liaison Services

Use of the Hospital Anxiety and Depression Scale in a Cardiac Emergency Room

Conceptualisation and Measurement of the Therapeutic Alliance

Cognitive Vulnerabilities to the Development of PTSD: A Review of Four Vulnerabilities and the Proposal for an Integrative Vulnerability Model

Medial Prefrontal Cortex Plays A Critical and Selective Role in ‘Feeling of Knowing’ Meta-Memory Judgements

Is Schizoaffective Disorder a Distinct Categorical Diagnosis?

‘Development of Criteria for a Diagnosis’ or ‘The Pathology of the Midnight Snack’

A Meta-Analysis of Self-Help Therapy for Insomnia

A Balanced Psychology and a Full Life

Can the Brain Understand The Brain

The Delusional Misidentification Syndromes: Strange, Fascinating, and Instructive

Somatic Awareness and Body Distress Symptoms

Depression. An Important Comorbidity with Metabolic Syndrome in a General Population

Research Report on Pain and Depression in Older People

Literature and Happiness

A Meta-Analysis of Psychotherapy in Cluster C Personality Disorders

Social Psychiatry Article Reviews

A History of Human Brain Mapping

‘It’s Good To Blog’ – Nature

Mental Health Advocates Supplementary Guide

Breaking Down Barriers

Making the CPA work for you

Choosing Health: Supporting the Physical Health Needs of People with Severe Mental Illness

Mental Health Taskforce: An Introduction was reviewed here

Transforming the Quality of Dementia Care: Consultation on a National Dementia Strategy

Capabilities for Inclusive Practice

Vocational Services for People with Severe Mental Health Problems

Consultation Response and Analysis. National Dementia Strategy

The Journey to Recovery – The Government’s Vision for Mental Health Care

National Service Framework for Mental Health

New Horizons: Towards a Shared Vision for Mental Health

Mental Health Review Tribunal Report

Comparison of Consultation-Liaison Services in the United States and Japan

Huntington Disease in County Donegal

Software Support for Huntington’s Disease

The Decline and Resurgence of Vascular Dementia

Social Networks and Their Role in Preventing Dementia

Dementia and It’s Implications for Public Health

Editorial on the Prospects of Psychosomatic Medicine

A Primary Care Psychiatry Program

Accuracy of Prevalence Rates in Multiple Sclerosis

The Genetic Epidemiology of Neurodegenerative Disease

Comparability of the Clinical Diagnostic Criteria for Vascular Dementia

Commissioning and Access to Psychological Therapies

Mental Health Ten Years On: Progress on Mental Health Care Reform

NIMHE – Establishing the Mental Health Research Network

Mental Health Perspectives from the Carribean Diaspora

The Social Connectedness of Older Adults: A National Profile

Research in the Field of Psychiatry

Social Buffering. Relief from Stress and Anxiety

Modernising Mental Health Services for People Who are Deaf

What Should Psychiatrists Be Doing in the 1990’s?

Estimating Future Numbers of Adults with Profound Multiple Learning Disabilities in England

Web 2.0 Tools in Medical and Nursing School Curricula

Why Is There Paper In The Paperless System?

Can Wireless Text Messaging Improve Adherence to Preventive Activities? Results of a Randomised Controlled Trial

Developing Services for Carers and Families of People with Mental Illness

Topic Selection Process for Technology Appraisals. A Consultation Document

Ubiquitous Healthcare Service Using Mobile Phone Technology

The Use of Health Information Technology in Seven Nations

Using the Internet for Health Related Activities

Health 2.0 and Medicine 2.0: Tensions and Controversies

The Neuroscience Information Framework

Prescriber Attitudes Towards PDA Prescription-Assistive Technology

The Alignment of Information Systems with Organisational Objectives and Strategies in Health Care

US Public Survey of Mobile Health Technology

Junior Physician’s Use of Web 2.0 for Information Seeking and Medical Education. A Qualitative Study

Mobile and Fixed Computer Use by Doctors and Nurses on Hospital Ward