Search

The COVID-19 pandemic has challenged the Swiss mental healthcare system. Many services were downsized or closed, and admission to treatment and care institutions was restricted during lockdown. These measures were necessary according to the general containment and mitigation strategies of federal and cantonal authorities, but this situation has had negative consequences for care and treatment of service users. This paper asks for a rethink of key aspects of the Swiss mental healthcare system that have been demonstrated not to be adaptable to the pandemic. In particular, the paper suggests diversifying care and treatment settings, and strengthening outpatient and outreach services. Finally, some proposals to foster social inclusion during and after the pandemic are outlined.

Background and Introduction Last year’s introduction of ResearchKit, an open source toolkit for iOS facilitating the creation of smartphone research apps, has sparked renewed interest in smartphone-driven biomedical research. In addition to the initial five research apps, about a dozen more ResearchKit-powered apps are now available to iOS-using participants in the United States. In April 2016, ResearchStack – the Android counterpart to ResearchKit – has been released, enabling researchers to finally include participants using the most popular mobile operating system. The field now has powerful informatics tools at its disposal, but it still needs to prove that the approach of collecting patient data for biomedical research via smartphones is useful and sustainable. Methods The C Tracker study is an apps-based trial, assessing hepatitis C patients’ activity levels over time. The app distributes surveys to study participants on a 2-weekly basis and returns activity data, such as steps taken and time spent exercising, along with survey answers. Users are identified by a random number, all data is de-identified and encrypted before being sent over the internet. The well-known i2b2 research backend serves as data storage. To provide value to participants, the app also contains a dashboard showing their recent activity, resources informing about hepatitis C and its treatment and other tidbits, such as a map of the US, showing participant origin. We are bringing C Tracker to Switzerland, extending its target population from anonymous “in the wild” recruitment to patients already enrolled in the Swiss Hepatitis C Cohort Study (SCCS). The data delivery toolchain, available open source under the name “C3-PRO” and using the upcoming Fast Healthcare Interoperability Resources (FHIR) standard, is extended with a separate backend system storing participant identity data, linking the app’s user identifier to participants’ SCCS study identifier. Circumnavigating the cloudy waters of electronic consent in Switzerland, we collect paper-based consent from participants during their annual clinic visit, at least initially. We are also adapting our toolchain to ResearchStack and hope to port the complete app to Android in a timely manner. Results & Discussion At this early stage in the project, we have identified steps in the original approach in need of adaptation to Switzerland. Most importantly, we have built an “identity manager”, allowing us to collect paper based consent from patients, recording the consent electronically and provide participants with a link to “unlock” the app, allowing access to the research study part of the app as a fully consented user. While this adds another system that research coordinators need to use, its use is straightforward, only requiring entry of five data items. The link to the app can either be established immediately via QR code or by emailing a link to the participant that will open the app. We are in the process of finalizing the server components and the app and hope to enroll our first participants in the near future. All our tools will be made available open source.

The present paper addresses the psychodynamics of severe depression. It argues that it is not loss or separation as such that cause depression; loss and separation are implied in the normal human psychosocial development. Nevertheless, specifically for the depressed person, it is impossible to acknowledge loss and to mourn. The consecutive feelings of despair cannot be transformed, and that in turn leads to deficits in symbol formation, to a paucity of pictorial and verbal psychic representations. What are the predisposing factors leading to this kind of "speechlessness"? Although not an exclusive factor, the quality of interpersonal relations is nevertheless very relevant. Two relational patterns have to be differentiated: (1) the relation to the object that is lost, e.g. the person whose death provokes melancholia (when the "lost object" has been too remote, too inaccessible, or if it has been too close, in both cases it will be difficult to overcome loss); (2) the object relations that serve as or supply a frame, a structure that helps to integrate adverse experiences like loss and separation ("structuring object"). That is the core concept underlying the psychoanalytic term of triangulation. In the psychotherapy of severe depression it will be a central issue to help to integrate loss and separation and overcome concomitant feelings of despair. The therapist may serve both as a "lost object" and a "structuring object". Using transference as a therapeutic tool, he enhances the revival of the essential object relations in the therapeutic relationship; thus he will sooner or later but invariably be experienced like the "lost object". By commenting on and interpreting these relational patterns, he will become a "structuring object", using triangulation for the patient to eventually find words for the hitherto unthinkable. Concluding the paper, a caveat is necessary to limit otherwise unrestricted and unrealistic therapeutic aspirations. Through therapy loss and traumatisation cannot be eradicated and dissolved. Instead, mourning may take the form of a "heavy mourning", as the French philosopher Paul Ricœur has suggested. Heavy mourning acknowledges the contingencies of adverse life experiences and even guilt and leads to forgiving. ― These dynamic characteristics of depression are explained in reference to some works of art (Tischbein, Holbein, Cranach, van Gogh and Michelangelo).

The Swiss Archives of Neurology and Psychiatry were founded in 1917 by Constantin von Monakow. The main motivation was the growing need for an independent Swiss journal. Previously Swiss neurologists had had to submit their scientific contributions to German or French journals, with the result that they were often insufficiently informed of their own compatriots' work. For the Swiss Neurological Society, established in 1908, the foundation of the Swiss Archives was also a milestone in its battle to be accepted as an independent medical faculty. While the papers were mainly Swiss authored, the Swiss Archives also occupied a significant international position from the outset, as witness the regular contributions from well-known European neurologists. Constantin von Monakow remained editor-inchief until his death in 1930. Most of the famous (neuro-)scientific-philosophical works written during the last 15 years of his life were published in the Swiss Archives. Certainly the most outstanding volume was No 13 (1923), which contains 52 articles by the most renowned neurologists, psychiatrists, neuroanatomists and physiologists of that time as a festschrift for Constantin von Monakow's 70th birthday. After Constantin von Monakow's death, R. Bing (Basel) and M. Minkowski (Zurich) took over as editors of the neurology section. Both neurologists published a considerable number of papers in the Swiss Archives and contributed greatly to the quality of the journal, not least through their contacts with scientists from all over the world. It was in the Swiss Archives that M. Minkowski published his well-known work on the course of the optic nerve fibres (1920) and studies on the reflexes of the human foetus (1924,1925). The 1st International Neurological Congress, which took place in Berne in 1931, was an important event in the history of Swiss neurology and formed the subject of a commentary in the Swiss Archives. At the end of the congress all the participants received a presentation copy of the most recent volume of the Swiss Archives. During the years preceding World War II the Swiss Archives played a remarkable international role by continuing to publish foreign papers, despite growing nationalism and racism in the surrounding countries of Europe. The journal also appeared regularly during the war. In 1959 the neurosurgeon H. Krayenbtihl, who in 1941 had published his classic work on cerebral aneurysm in the Swiss Archives, became editor-inchief. During his editorship the journal's name was expanded to Swiss Archives of Neurology, Neurosurgery and Psychiatry (until 1986). The most cited papers since 1945 have been those of R. Adams (on normopressive hydrocephalus) and B. Roth (on narcolepsy and hyper-somnia). Several contributions have come from related specialities, e.g. the physiologist and Nobel Prizewinner W. Hess wrote on the autonomic nervous system, the anatomist G. Tondury on foetopathies and the paediatrician G. Fanconi on poliomyelitis.

Henning Muller, Eusebio Passaretti This special issue of Swiss Medical Informatics (SMI No 64) brings together the best articles submitted to the 21st Congress of the Swiss Society for Medical Informatics (SGMI-SSIM). The congress took place in Sierre (Valais) at the University of Applied Sciences Western Switzerland (HES SO) from 5–6 June 2008, and featured 4 invited presentations, 19 oral scientific presentations and 6 scientific posters. In total, 27 papers were submitted and reviewed by the scientific programme committee on the basis of novelty of approach and technical quality of presentation. From this evaluation process the best eight papers were selected for the present special issue covering a wide range of subjects from the field of medical informatics. Two other papers were added for their practical interest to SGMI-SSIM members, bringing the total up to ten papers. Two articles deal with financial analysis of hospital data [1, 2] and two with image management and storage [3, 4], partly in the context of diagnostic aid. The patient record is traditionally well represented at these conferences, from access models for research [5] to patient identification [6]. Finally, two articles on specific diseases or disease categories are presented [7, 8]. The articles additionally selected describe practical approaches, one to the choice of an integrated electronic patient record at the Inselspital Berne [9], and the other on context-navigated search inside a clinical patient record [10]. In the first article [1] Rodolphe Meyer describes an extensive analysis of data on hospitals to define models measuring the impact of particular information and communication technologies on hospital productivity. This paper also received the award for the best scientific contribution to the conference. Alexandre Gnaegi [2] then describes a project on data mining within attributes of a hospital’s data warehouse in order to estimate income for released but not fully coded patients. The goal is to estimate the income for cases that have left the hospital within a reporting period but have not been fully coded. Off-the-shelf data mining tools have markedly increased the precision of such estimations for the Valais hospital network. Mechthild Uesback [3] describes the introduction of a PACS in Zurich University Hospital from 2004–2007. The results were major space savings and financial gains, with optimisation of workflows engendering a more productive work environment. Adrien Depeursinge then presents a diagnostic aid tool for emergency radiology [4] in the diagnosis of interstitial lung diseases. The tool analyses the texture of the lung tissue in CT images to classify it into healthy and several abnormal tissues. Clinical data are also taken into account since age or environmental factors can significantly change the lung texture properties. Jimison Iavindrasana’s article [5] reports on a framework for data access to a life clinical record with all its security constraints. The context is the EU project AneurIST whose aim is to improve the treatment and understanding of cerebral aneurysms. Tobias Mettler [6] then presents an approach to patient identification and tracking in a processoriented manner. A global view of the identification process across organisations focused on the patient can significantly improve identification. Marc Oertle [7] describes another diagnostic aid tool which targets patients with chronic heart failure and implements evidence-based medicine using information and communication technologies. The goal is standardisation of the care process to reduce variability in treatment. Christina Lovis [8] then outlines another European Union-funded project also targeting a particular group of diseases: nosocomial infections. The goal of this project is to develop new ways of fighting antibiotic resistances of bacteria by analysing large amounts of routine clinical data. The outcome of this project is expected to be IT-biotics, IT technology to fight bacteria. Oliver Handgratiger [9] describes, in the setting of the Inselspital Bern, the process of selecting a new electronic patient record covering all medical specialties and partners in the hospital, and outlines the criteria for selecting a particular solution. The effort to obtain each criterion with its discriminative power is then described. This practical and detailed approach should be useful for other hospitals as well. In the last article of this issue, Ela Bielecki [10] presents Solothurn hospital’s project for Prof. Dr. Henning Muller University of Applied Sciences Sierre & University and Hospitals of Geneva Business Information Systems Institute HES-SO Valais, TechnoArk 3 3960 Sierre, Switzerland henning.mueller@hevs.ch

Neurology and neurosciences are becoming more and more specialised, and research in the field is creating an enormous amount of data. In our daily practice we need ofte n specialist and dedicated persons, with knowledge, and a clinical and academic approach, to summarise the data. This is why in the surveys you completed, a majority asked, among other points, for more reviews on current topics. This is why we propose, for the next issues of SANP, an orientation towards educational dossiers, particularly on topics that were proposed at the last SNG Congress in Interlaken, during the 190th Annual Meeting of the Swiss Neurological Society, in collaboration with other societies, particularly the Swiss Society of Intensive Care Medicine. The first dossier comes from some of our neurointensivist colleagues, who kindly agreed to write a report on what they presented. ICU Teachers were the fir st to send their manuscripts and we propose to present their refle ctions, which are also important for neurologists. Bernard Frey presents some arguments on how problems should be handled in the diffic ult case of Hypothermia in paediatric traumatic brain injury: cons . His paper does not question the importance of hypothermia in the intensive management aft er asphyxia or cardiac arrest where it has very interesting results, but aims to make doctors cautious on some points potentially related to issues when hypothermia is proposed afte r TBI, at least in children. The second paper is a minireview on Glucose control in the ICU, by Karin Amrein and Tadeja Urbanic Purkart; this is a very important topic also in neu rology – particularly aft er stroke – and the authors remind us that glucose should be ideally kept under 150 mg/dl in the ICU, although the margin is less strict in patients with preexisting diabetis. A third ICU paper will appear in the next issue. Finally a case report Malformation d’Arnold-Chiari et apnee centrale du sommeil by Guinhouya et al. reminds one that interesting case reports are welcome in our journal. Enjoy the reading.

The present debate paper addresses four relevant issues related to the impact of intensity of practice after stroke. First, the best way to define intensity of practice is discussed. Second, the paper describes the evidence that exists for a dose-response relationship in stroke rehabilitation. Third, the relevance of an appropriate patient selection for a meaningful intensive practice is explored. Finally, the feasibility of intensive practice by: (1) early started mobilization of stroke patients (2) ability to practice in groups, (3) using forced use paradigms such as constrained induced movement therapy for the upper limb, (4) using robotics and (electronic) devices that help patients to practice on their own and (5) preventing poor compliance in terms of practice in therapeutic sessions by identifying factors that predict poor adherence are discussed.

s presented during the congresses had a high chance of being published, usually in papers with a good IF. This reflects the good quality of research in cardiology in Switzerland.

Symbolizations of final parting. On the imagery of the dying Empirical studies show that those nearing death are commonly overtaken by intense imagery. They require appropriate spiritual support during this experience. This paper lays out results from the research project entitled “Hermeneutic of trust at the end of life” and sponsored by the Swiss National Science Foundation as part of the national research program “End of Life” (NFP 67). This project entailed surveying clinical pastoral caregivers in terms of their observations and assessments regarding such occurrences. Besides quantitative results, the study yielded an abundance of qualitative data. Example vignettes in this article demonstrate that near-death imagery is wildly diverse and by no means adheres to a single pattern. That said, it appears essential for spiritual caregivers to recognize certain recurrent themes.

BACKGROUND: The implementation of mobile phone apps for patient care in hospital settings requires careful consideration of many challenges. We developed and pilot-tested a mobile app to support nursing workflow at the bedside in our institution, and are currently deploying our solution on a large scale.AIM: In this paper, we present our considerations and approach to the large-scale deployment of our mobile app.METHOD: We reviewed our experience in designing and developing this mobile app from its creation to its deployment. We identified prior and new challenges when preparing for large scale deployment, and discuss our approaches to overcome these challenges.RESULTS: We identified the specific challenges encountered during large-scale deployment and addressed a large range of problems including maintenance, security, logistics and acceptance aspects of such a deployment.DISCUSSION: Issues encountered at early stages of the development process must be reconsidered during large-scale deployment. The rapidly evolving context, such as the technology and the stakeholders' opinions, can influence the acceptability and more generally the overall feasibility of the envisioned solutions. Adopting an incremental approach can allow for adjustments during the take-off process.

Our society has chosen Integrated Care as main topic for the conference. Not only health managers and politicians are talking about integrated care as one of the most important scenarios in healthcare for the very near future. In the last decade, information officers invested most of their time in completing homework within their institutions. Clinical information systems were implemented, processes have been redesigned, clinical decision support has been implemented, and steps toward automatisation and personalisaton have been made. However, many of these efforts never crossed the borders of a hospital or a private practice. In the next decade, building transition of information will be much more in the forefront of our daily work than it is today. So that we can profit most from current experiences, this congress will show some existing pilot systems dealing with information transfer across institutions, cantons or even the country. We should learn as much as we can from pioneering groups and from practice examples, as Switzerland is lagging behind many other countries in terms of eHealth. Hopefully, the boards of directors in Swiss hospitals will recognise the signs of the times, the potential lying in information technologies, and will support the efforts made by information managers. A second important theme of this congress covers the evidence base behind our daily work. Not only do we know many things about how to design and implement information technologies, but we also have to learn from our failures. Contributions by international and national speakers will focus on how to perform – and how not to perform – in our area of interest. Not surprisingly, errors occur most where we don’t tailor our information systems to information needs and work processes, and also where we make too-rigid rules. One area of concern in this context – as shown during the congress – is data protection. The interpretation of our data protection laws, which resemble a pendulum swinging from the paper period when there was no real data protection to a period where data protection finally decides the possibilities in work with information technologies, determines many ICT implementations in these days. And they provoke e-iatrogenesis! In coexistence with the main topic of integrated care, all stakeholders should engage in working together and finding common, consensual solutions for the best of our healthcare systems! I finally wish you two intensive, vivid, interesting and communication-full medical informatics days!

Research in the healthcare domain requires the collection of important and exhaustive datasets in order to validate a scientific hypothesis, or to assess the effectiveness of a treatment, technology, medicine, or procedure. The data acquisition phase for this type of work requires an often under-estimated amount of time and effort, while needing to maintain high quality standards for the entire process. Many of the tasks associated with data acquisition are often carried out manually, resulting in error-prone procedures, hand-transcription, inaccuracy, and time delays to produce a usable dataset. This paper presents MedRed (medical research data acquisition platform), an interface and a service designed to facilitate the data acquisition process for researchers in the healthcare domain, and using REDCap software for data capture. This service is available first of all to all scientists at the HES-SO (University of Applied Sciences and Arts Western Switzerland) schools in Switzerland, and is partially supported by the Swiss universities’ CUS-P2 programme.

In this paper, we reflect on ways to improve the quality of bio-medical information retrieval by drawing implicit negative feedback from negated information in noisy natural language search queries. We begin by studying the extent to which negations occur in clinical texts and quantify their detrimental effect on retrieval performance. Subsequently, we present a number of query reformulation and ranking approaches that remedy these shortcomings by resolving natural language negations. Our experimental results are based on data collected in the course of the TREC Clinical Decision Support Track and show consistent improvements compared to state-of-the-art methods. Using our novel algorithms, we are able to reduce the negative impact of negations on early precision by up to 65%.

Summary This paper describes some of the concerns that motivated the committee d eveloping the new classification of personality disorders for the DSM-V. They included the tension between empirical research on normal populations, on the one hand, and clinicians interested in the personality disorders constellations found in clinical settings, on the other. This tension was e xpressed in the controversies between categorical and dimensional a pproaches to the classification. There also was an effort to relate a dimensional system of concrete behavioural traits with neurobiological and genetic markers. In addition, there was also a tension between neurobiological and psychodynamic approaches. A major compromise was reached in a “hybrid,” dimensional and c ategorical approach that maintained six of the ten categories of the DSM-IV systems, while developing a dimensional approach to a general level of p ersonality function centered on the pathology of the experience of the self. This included the assessment of identity, the experience of oneself, selfesteem and self-appraisal, and emotional regulation; and self-direction. It also included the assessment of interpersonal functioning as reflected in the capacity for empathy and intimacy. In a critical review of this proposal, the author expresses his general agreement with the main thrust of this proposal, the emphasis on identity and interpersonal functioning and their pathology, and points to the fact that this emphasis corresponds to central concerns of psychodynamic approaches to personality pathology. Regarding the selection of six of the ten personality prototypes of DSM-IV, the criteria for the elimination of the paranoid, schizoid, histrionic, and dependent personality disorder, and the depressive personality disorder (in the appendix of DSM-IV) may be questioned in terms of their prevalence and clinical significance. An underlying problem may be the fact that we do not yet have an integrated understanding of the interplay of neurobiological and psychodynamic structures in the development and psychopathology of the personality. In any case, the introduction of the pathology of identity and interpersonal relations in the proposed DSM-V system seems an important step forward.

Psychogenic non epileptic seizures (PNES) look like epilepsy, but are not accompanied by the electrophysiological alterations found in epilepsy. The diagnosis requires a complex process at the interface between neurology and psychiatry. Diagnostic restitution to the patient and treatment of the condition should be a collaboration between neurologist and psychiatrist including as much as possible a general practitioner. Vulnerability and triggering psycho-social factors, as well as frequent psychiatric co morbidity implicate that psychiatric-psychological care is needed in a majority of situations, however this cannot be done without a strong "somatic back-up" with rapid access to somatic facility for advice and care when needed. The neurological presentation of the disease, with psychiatric causes underlying the condition, bear the risk for the patient that neither neurological nor psychiatric care is offered. Current knowledge about the condition is still scarce, but the field is progressively enriched by studies with stronger methodologies. Recent neuroimaging studies open fascinating avenues on our understanding of the interplay between emotional regulation, representation of the self, and dissociative symptoms. These new avenues help our understanding of these disorders which challenge classical frontiers between neurology and psychiatry. In this paper we try to formulate a framework for the care of patient with dissociative disorders including NEPS.

Background: Psychomotor symptoms are important for diagnosing psychiatric disorders. The concept of psychomotorics has not changed in 150 years, basically. Social and interactional dimensions have not been included. Hypothesis: The paper argues in favor of an enlarged notion of psychomotorics taking cultural, social and interpersonal criteria into consideration. To account for this conceptual extension, the term psycho-socio-motorics or interactional psychomotorics is introduced. Methods: Interactional psychomotorics is highlighted by the analysis of mimic interaction, either in everyday conversation or in psychopathological symptoms. Results: Developmental and phenomenological studies have convincingly shown that mimic interaction is characterised by prereflexive spontaneity and a reciprocal attunement between self and other. The psychological challenge implied in mimic interaction is three-fold: it is unavoidable, happens spontaneously and is susceptible to failure. Psychopathological symptoms such as dysmorphophobia can be understood as an attempt to avoid or shortcut these challenges. The psychosocial sequelae of Parkinson's disease and of parkinsonoid side ― effects of neuroleptic drugs are due to a loss of balance in mimic interaction. Conclusion: Widening the notion of psychomotorics to include social and interactional dimensions allows an expanded understanding of psychopathological symptoms. Actual research methods to assess bodily experiences and an actual research project on facial expression and its impact on identity formation are finally touched upon.

This paper examines the sensitivity of the Aberrant Behaviour Checklist (ABC) in an Indian population with intellectual disability. The ABC is a reference tool largely used to rate behaviour disorders in the population with intellectual disability and commonly used in Geneva institutions. The present study compared ratings obtained in an Indian institution with those obtained in a Swiss institution. The study was conducted at the "Lebenshilfe Institute", Andhra Pradesh, India, and at the institution "La Castalie" in the canton of Valais in Switzerland. The participants with intellectual disability were assessed with the ABC on two occasions, in 2005 and 2006. No significant differences were found in ABC scores between the 2005 and the 2006 collections. Additionally, higher ABC scores were observed for one factor in the Swiss sample.

Surgical repair of tetralogy of Fallot (TOF) may be followed by various conditions and residual findings, early postoperatively or late during follow-up. Most of these conditions affect the right ventricular outflow tract and the pulmonary arteries and thus, indirectly, the right ventricle. This paper discusses the role of the right ventricle during the natural history of repaired TOF. The different imaging methods used to assess the function of the right ventricle in relation to this congenital heart disease are highlighted. Particular attention is focused on the volume overloaded right ventricle, as this condition is nowadays a subject of intense discussion, particularly regarding the appropriate timing for pulmonary valve replacement. The most recent literature on this topic is briefly reviewed. In summary, preservation of right ventricular function and prevention of right ventricular arrhythmias are crucial for these patients’ survival and outcome.

The HONcode provided by Health On the Net (HON) foundation is the most successful third party certification initiative. In nearly 20 years, it has acquired a database of over 8000 trustworthy health websites, has been translated into over 30 languages and become not only a well-respected name amongst health information providers but also an increasingly well-recognised brand amongst health information end-users. The HONcode, having begun in the mid-1990s has managed to stay current and relevant two decades on, because of its ability to change and remain relevant to the present times. The past few years have been no different, and HON has been heavily involved in bringing out certain updates to further its mission of unrestricted trustworthy health information online. In this paper we present the HONcode certification process and the main changes taking place in the certification process to enable its continued success and sustainability.

Stress abbauen bei Patienten auf der Traumastation – das ist die Idee des «Modularen Kokons», der in der psychiatrischen Klinik Littenheid eingesetzt wird. Entstanden ist er im Rahmen eines Forschungsprojekts in Zusammenarbeit mit Designerinnen der Hochschule Luzern. Dieses Projekt zu besseren Gestaltung von Patientenzimmern erhielt den 3. Preis beim «Call for Paper in Medical Humanities» der Akademien der Wissenschaften Schweiz.

De nombreuses personnes âgees sont confrontees a des troubles cognitifs. Une equipe composee de psychologues, psychiatres, anthropologues et sociologues s’est penchee sur le diagnostic des troubles cognitifs, l’annonce aux patients et a leurs proches et l’impact de ce diagnostic sur leurs projets de vie. Une etude recompensee par le troisieme prix du «Call for Paper in Medical Humanities» de l’Academie suisse des sciences.

Fur diese Arbeit gab es den zweiten Preis beim «Call for Paper in Medical Humanities» der Akademien der Wissenschaften Schweiz. Die Fragestellung: Wie konnen Erkenntnisse aus der Kommunikations- und Kollaborationsforschung in Rehakliniken fur die Arbeit in der Klinik nutzlich gemacht werden? Verschiedene Fachpersonen haben bei dieser Untersuchung zusammengearbeitet: Soziologinnen und Physiotherapeutinnen, Mediziner und Pflegefachpersonen.

Summary Eiser AS, Schenck CH. Dreaming: a psychiatric view and insights from the study of parasomnias. Schweiz Arch Neurol Psychiatr 2005;156:440‐70. This paper provides a psychiatric view of the psychological, experimental, and medical literature on dreams, along with insights gained from the study of parasomnias.The psychoanalytic theory of dreams developed by Freud considers dreams to be highly meaningful mental products, with unconscious processes playing a major role. However, it has been quite difficult to devise operational criteria to rigorously test this theory.With the discovery of REM sleep and the NREM/REM sleep cycle, sleep laboratory techniques facilitated the systematic sampling of dreams. Studies carried out to examine dreams focused on their individual context were hampered by small sample sizes. Studies of dreams from larger samples of subjects involved in a particular and often disturbing life circumstance posed various challenges in interpretation. Experimental manipulations of REM sleep and associated dreaming have been carried out, with various theoretical and methodological shortcomings. REM sleep deprivation studies have suggested that REM sleep, and associated dreaming, may perform vital functions. Studies on the childhood development of dreaming are also pertinent. The neurobiology of REM sleep as the primary source of data from which to make inferences on dreaming was pioneered by Hobson and McCarley in their “activation-synthesis” model (recently updated as the activation/input/modulation-AIMmodel by Hobson), in which brainstem activation during REM sleep randomly stimulates the forebrain, which then attempts to “synthesize” the information into coherent dreams. In this model, dreams are not intrinsically meaningful, though some meaning may accrue through the forebrain’s efforts to “make sense” of its physiologically determined stimulation. Various problems with the activation-synthesis model have been identified. A recent critique by B. E. Jones discusses how brainstem activation of the forebrain can originate from highly ordered brainstem circuits that generate not only specific motor patterns but also complex organized behaviors. The possible relation to dreaming of the “hippocampal theta rhythm” in REM sleep is discussed. The “neuropsychology of dreaming” proposed by Solms is presented, based on the large study of neurological patients with widely distributed brain lesions. Neuroimaging techniques and their application to dreaming across the sleep-wake cycle are another new source of data. The second part of this article discusses abnormal dreaming with the parasomnias, which are the behavioral, autonomic nervous system and experiential disturbances that can accompany sleep. REM sleep behavior disorder is the prototypic dream-enacting parasomnia in which the characteristic generalized muscle paralysis of REM sleep, i.e. “REM atonia”, becomes compromised, allowing for behavioral release associated with stereotypically altered dreams involving the dreamer being threatened or attacked by unfamiliar people or animals. Sleepwalking and sleep terrors in adults, obstructive sleep apnea (OSA “pseudo-RBD”), nocturnal seizures and nocturnal dissociative disorders can also present with dream-enacting behaviors. The recently identified “epic dream dis

The study of emotion had been relegated to the fringes of neuroscience until quite recently because it was too subjective and irrational for the intellectual stiffness of modern science. Since about thirty years, the studies relating to emotions and underlying neural mechanisms have considerably multiplied utilising behavioural paradigms with normal subjects, clinical evaluation of patients suffering from neurological or psychic disorders, observations of patients with definite brain lesions and finally, using the most advanced and noninvasive technology available to capture revealing images of the living brain responding to emotions: functional brain neuroimaging. In this paper we describe the famous historical contributions to the comprehension of the links between brain and emotions. The oldest experimental demonstration of these links was carried out at the beginning of the twentieth century by Cannon and Bard who showed that the surgical ablation of a cat's neocortex induced non-motivated aggressive behaviour called "sham rage". Kluver and Bucy described behavioural modifications generated by the ablation of portions of temporal lobes in monkeys. After lobectomy, animals developed a submissive and docile behaviour and hypersexuality as well as hyperorality. The case of Phineas Gage first described by Dr Harlow is also very famous as first description of personality changes after prefrontal damage. These case studies carried out on man and animal lead to the establishing of assumptions on the anatomical basis of emotions. Researchers such as Papez, Broca, MacLean and more recently Mesulam have successively contributed to the construction of the current neuroanatomical models of emotions where the cortico-limbic system constitutes the essential substrate of the emotional processes. The main anatomical structures of this system, namely the amygdala, the septal area, the hypothalamus and the prefrontal regions are then reviewed. The most relevant data supported the implication of the septal area being involved in pleasure and the amygdala in fear-related emotion. As interface between cognition and emotion, the prefrontal area has a more complex role, particularly in the regulation of social emotions. The contribution of both cerebral hemispheres is also discussed with the classical opposition "happy" left hemisphere and "pessimistic" right hemisphere. The final paragraphs provide recent data on the relations between emotional states and specific patterns of regional brain activity seized with the help of the various functional neuroimaging techniques. These techniques, which allow to study the emotional processes in healthy subjects "in vivo", challenge the hypothesis that specific brain regions have strictly specialised functions for the generation of emotions (e.g. the critical role of amygdala in fear-related processing). It is indeed likely that separate brain regions are involved in different aspects of emotion (e.g. the amygdala may not exclusively respond to threaten stimuli but to any emotionally relevant stimuli, regardless of valence). As in other domains of neurocognition we are moving from a localisationist perspective toward approaches where the mental functions are underlain by distributed neural networks. Although our knowledge of emotional mechanisms and their anatomical substrates is still fragmentary, the study of emotions constitutes a promising field of investigation.

Based on our growing knowledge about motor learning, mechanisms of motor recovery and central neuronal plasticity evidence based therapeutic strategies of stroke rehabilitation have been developed in the recent years. Modern therapeutic strategies share common elements crucial for functional recovery of both upper and lower extremity and, therefore, should be a part of every therapeutic session. These elements are repetitive practice of simple movements over eight minutes at least, performance adaptation on patients functional recovery (shaping), training on the individual limit, execution of task-specific and goal-directed exercises and implementation of training elements into everyday motor performances. The present paper provides the state of the art of evidence-based therapeutic procedures in stroke rehabilitation.

The two large landmark single-centre randomised controlled trials in Leuven, Belgium, showed a substantial and signifi cant clinical benefit for intensive insulin therapy (IIT, target 80–110 mg/dl) in adult surgical and medical critically ill patients. Therefore, tight glycaemic control was implemented in guidelines and in clinical routine in intensive care units (ICUs) all around the world, ofte n at the cost of an increased incidence of moderate and severe hypoglycaemic episodes. Surprisingly, in sub sequent large multicenter trials the same effe ct could not be replicated. Currently, the debate on how best to implement glucose control in the ICU is lively and ongoing, but a recent consensus paper on glycaemic control in critically ill adults has clarifie d many aspects [1]. It is likely that the same rules apply to other severely ill patients who are not necessarily in ICU and to hospi