Dr Shock MD PhD

Optimal Target for Deep Brain Stimulation for Depression

Dr Shock — Tue, 09 Feb 2010 07:08:18 +0000

The strongest evidence exists for Broadman Area 25 in the subcallosal cingulate gyrus (SCG) as target for deep brain stimulation in treatment resistant depression. This area in the brain is depicted in the figure above and is from the most important publication about DBS and depression in Neuron march 2005 by Helen Mayberg. Functional neuroimaging as well as antidepressant treatment effects suggest that this area plays an important role in modulating negative mood states. A decrease in activity is reported with clinical response to antidepressants and electroconvulsive therapy (ECT).

But depression is not a disease of a single brain region nor neurotransmitter system. It is now generally viewed as a systems-level disorder affecting integrated pathways linking select cortical, subcortical, and limbic brain regions with their related neurotransmitter systems.

Suggestions of other brain localizations for treatment with DBS for depression comes from case reports with DBS for other indications than depression. These localizations have been described in a peer reviewed article with excelent graphics.

In a recent study done by the “Mayberg group”, Toronto, Canada, the autors compared the location of the electrode contacts in responders and nonresponders to DBS of the subcallosal cingulate gyrus (SCG) and correlated the results with clinical outcome to help in identifying the optimal target within the region.

On postoperative MRI scans the researchers did complicated mapping procedures to pin point the locations of the active contacts on the implanted electrodes. There was no difference when the right and left electrodes were compared in patients. So both electrodes were exactly placed on each side (hemisphere). The only significant difference they found between responders and nonresponders was that electrodes in patients who responded were in a slightly more ventral position relative to the anatomical landmarks used in the medial prefrontal lobe. This difference between responders and nonresponders did not exceed 1,5 mm. The authors is not likely to be of clinical significance, according to the authors. This small difference is probably unimportant compared to the clinical features of the patient for the outcome of the DBS procedure in depression. Another limiting factor on this research is the small sample size, in larger groups these results might differ.

What we can conclude based on our findings is that within the small targeted region of the SCG, the location of the electrode contacts did not determine outcome.

This article also describes a detailed method for a more standardized method for targeting the SCG with DBS for depression. This is to technical to reproduce in this post but those working with DBS for depression should have a look at this procedure. From this study it is still not clear whether DBS of other brain areas might be more superior in efficacy. And is brain area more important than clinical features of the patient or do the areas differ for different types of depression? All very interesting questions and topic for more research on DBS.

Hamani, C., Mayberg, H., Snyder, B., Giacobbe, P., Kennedy, S., & Lozano, A. (2009). Deep brain stimulation of the subcallosal cingulate gyrus for depression: anatomical location of active contacts in clinical responders and a suggested guideline for targeting Journal of Neurosurgery, 111 (6), 1209-1215 DOI: 10.3171/2008.10.JNS08763

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The Hidden and Informal Curriculum During Medical Education

Dr Shock — Mon, 08 Feb 2010 07:26:59 +0000

Both the hidden and informal curriculum take place after or next to the theoretical teaching, the formal teaching and has an important part in the shaping of the medical students’ professionalism and professional values. Moreover, these forms of the curriculum have a major impact on the learning potential of med students. Yet little is known about this subject. A lot has been written but only from a theoretical stand point.

The hidden curriculum is the physical and workforce organizational infrastructure in the academic health center that influences the learning
process and the socialization to professional norms and rituals.

The informal curriculum is the student’s immersion in the interpersonal processes in the academic health center, including
interactions between students and their teachers, interactions among the interprofessional participants in medical care processes, and interactions that students experience with patients and their family members.

Recent published research studied the informal and hidden curriculum by using medical students’ critical incident narratives. Medical students were asked during their third year clerkship in internal medicine to report professional critical incidents, events that thought them something about professionalism and professional values or the lack thereof.

reflect on and write about events, either positive or negative, that “taught you something about professionalism and professional values.”

Each students had to write at least two such narratives online in a web based password protected web site. These narratives were printed and discussed anonymous in focus groups, monthly small group reflection sessions. From the 272 experiences described by the students, 63,4% were positive and 29,1% negative. The other stories were not positive nor negative. The main domain about which these narratives were focused were about medical clinical interaction (81,3%) and 18,6% about educational situations.

Most common themes:

manifesting respect or disrespect in clinical interactions with patients, families, colleagues, and coworkers. For instance face to face contact with patients or conversations about colleagues in their absence
managing communication challenges with patients and families. Mostly positive stories about the positive amnner in which professionals handled these contacts. Some stories were clumsy in handling sensitive conversations about important topics
demonstrating responsibility, pride, knowledge, and thoroughness. Role models showing actions that either were poor or exemplary behaviors.
stories about professionals taking time to understand their patients’ concerns and needs and making certain that patients understood what was being said about their illnesses
going above and beyond, caring and altruism in taking care of patients and/or family members
stories concerning communicating and working in teams and about the issue of teamwork
creating an (un)welcoming environment. This is mostly about teaching and the learning environment. The feeling to be actively taught and cared for is extremely important for students
The teacher asking questions and providing explanations, using all opportunities to teach values and manners, also an important educational theme for the students.

These themes show how utterly important it is to be a good professional role model to medical students. They focus mainly on interaction and communication. They mostly have their attention on the respectful or lack thereof interactions in teams and towards patients and many others. Obviously med students are very sensitive to these communications and dependent on role models for their future. They observe very closely how their mentors interact with various others, both visible and behind closed doors.

I don’t think negative interactions or incidents will have a negative effect, these things happen. What counts is the way we solve these negative behaviors, how we deal with them. If we succeed to deal with them in a positive manner, these incidents become educational. What do you think?

Karnieli-Miller O, Vu TR, Holtman MC, Clyman SG, & Inui TS (2010). Medical students’ professionalism narratives: a window on the informal and hidden curriculum. Academic medicine : journal of the Association of American Medical Colleges, 85 (1), 124-33 PMID: 20042838

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Simulate the Human Brain using an IBM Computer

Dr Shock — Sat, 06 Feb 2010 13:08:25 +0000

Bluebrain | Year One from Couple 3 Films on Vimeo.

The Blue Brain Project is the first comprehensive attempt to reverse-engineer the mammalian brain, in order to understand brain function and dysfunction through detailed simulations.

10 Websites With The Best Information on Depression

Dr Shock — Fri, 05 Feb 2010 07:37:28 +0000

After searching for websites about depression (‘‘depression,’’ ‘‘depression treatment,’’ and ‘‘depression help’’) with a popular search engine: Google, the authors of this work carefully examined the websites. The websites were evaluated on accountability, interactivity, esthetics, readability and content quality. They also used the brief DISCERN as a content quality indicator for general consumers. They found 58 sites from which 13 were excluded: 8 were not websites, 3 were blogs or
discussion forum, 1 required an access login, and 1 was inaccessible.

They analyzed 45 websites, the overall quality of the websites about depression was good. Those with a high score on the brief DISCERN, the presence of HON label (The Health On the Net Foundation (HON) ) and affiliation of the website were all related to high quality.

These 10 websites scored highest on the brief DISCERN and content quality:

This research was done in February 2009.

Zermatten, A., Khazaal, Y., Coquard, O., Chatton, A., & Bondolfi, G. (2010). Quality of web-based information on depression Depression and Anxiety DOI: 10.1002/da.20665

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What To Do With Business Cards in this Digital Era?

Dr Shock — Thu, 04 Feb 2010 12:10:29 +0000

Business cards are still around, I get them often, they’re nice and they do have advantages as can be read on geek!daily: they’re customizable, trivial to distribute, and cards are static. Digital alternatives like Poken and My Name is E don’t seem to have enough success, only nerds and geeks not your average academic or business man has any of them. There are alsoother ways to use the internet to create, share and use your business card, but again not in much use by doctors, scientists and academics.

I often ask myself how to get a grip on these business cards of which the social calling cards like moo cards were a recent hit. Several different options exist for digitalizing your paper business cards or social calling cards:

You can get a business card scanner. They are small usb scanners and the accompanying software can be used to also grab the contact information in an email signature, web page or other text file and put it in the software which transforms it to Outlook or other address book applications
You can mail, upload and email your business cards to CloudContacts. After they receive your business cards, they turn them into contacts you can view online and export in a variety of formats. You have to buy credits, 100 for 29,95 dollars. Each business card conversion is one credit.
Use Evernote. You can snap a photo with your iphone of a business card, tag it and and have an easy way to store and access contacts in Evernote. You can see it in the video below
You can also make pictures of the business cards and upload them to flickr and tag them

Recently I started using evernote with iphone for digitalizing paper business cards but I am thinking about getting a card scanner because the photo’s don’t work that well and I don’t want a case for my iphone. Do you know any alternatives? Any suggestions or advice?

By the way, did you know you can use your twitter account for digital business card with TwtBizCard

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PresentationZen Design Book Review

Dr Shock — Wed, 03 Feb 2010 07:26:33 +0000

PresentationZen Design the new book about principles and techniques for presentations by Garr Reynolds is a follow up from Presentation Zen reviewed in a previous post on this blog. This book is more practical, not a step by step instructions but it has many good examples and offers good advice. For instance which fonts to use, between all those fonts on your computer about 6-8 will do the trick. It boils down to 6-8 fonts and your all set. Instructions how to use Kuler for generating a color theme.

How to communicate with color but also how to acquire good colors for your presentation based on the content and message you want to get across. How to use images and especially videos during presentations. The book is full of very useful and new examples, tricks and advice. The chapter on presenting data is even better than the chapter in the previous book.
The three chapters on principles of presentation design are about the use of space, creating purpose and focus and achieving harmony. He does his best to show you how these design principles depend on your message and how to get this message across with design.

The book is full of excellent examples of slide design but also has other specialists in their fieled giving additional advice such as Scot Kelby sharing 10 tricks for getting better-looking photos to use in your presentation, or Stephen Few’s graph design IQ test and many more specialists in subjects on design and presenting. Just one more example, Nancy Duarte from Duarte Design also an expert, about the role of sketching and planning analog. She also wrote an excellent book about presenting discussed on this blog in a previous post: Slide:ology

Should you buy the book even when you already have the previous one?
Yes definitely, learned even more from this book, more practical advice on making good presentations not only the design, go get it and enjoy.

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Selection Of Medical Students

Dr Shock — Tue, 02 Feb 2010 07:20:03 +0000

The government of The Netherlands has decided to abolish the numerous fixus (weighted lottery) for medical education. This meant that only 2850 students were able to go to med school a year. The numerous fixus was mainly based on high grades on high school. Universities are allowed to make there own selection criteria for admittance to med school. They could still use the average high school grades but they can’t increase the number of medical students since medical education is very expensive. In The Netherlands a med student costs a 120.000 Euros a year, for comparison a students at Law school costs about 30.000 Euros a year.

But how do you select medical students. Which criteria should you use. Universities in The Netherlands have been experimenting with selection of medical students. One of them recently published the results of a controlled experiment. This experiment is unique since due to the transition phase in selecting students for medical education in The Netherlands they were able to compare different selected groups of medical students.

They compared 389 medical students that were admitted to medical education by selection with 938 students who had been admitted by weighted lottery between 2001 and 2004. The weighted lottery means that students with a undergraduate grade point average of 8 or higher ) on a scale where 1 is poor and 10 is excellent) have unrestricted direct access to medical school. Medical schools were allowed to select a maximum of 50% of their students on basis of other characteristics. So at the end they had 3 groups, the lottery system based on grades, in which the chance rises with the average grade, a group with unrestricted direct access (8 or higher average grade) and through local selection.

But how did they select the med students?

The main criterion was the quality and extent of extracurricular activities, so what else did the student do besides going to high school.

Only activities that had lasted for 2 years or more and had been carried out during the 3 years immediately prior to application were taken into account. These activities were divided into five categories:

activities in health care;

activities in management and organisation;

activities related to a talent (such as music, sport or science);

(extracurricular) academic education, and 5 additional pre-university education.

They also did five cognitive tests on a medical subject during 4 consecutive days.

Did this help?
The only significant difference between groups was a lower drop out rate of medical school , this was 2.6 times lower in the selected group compared to those admitted to medical education by lottery. The groups didn’t differ in the percentage of optimally performing students or grade points for their first examinations. The authors explain this with the argument that the selection process excluded most of the potential drop outs.

Hope they follow these groups to see how they are doing on clinical rounds, for me it’s still difficult to define good students that will become good doctors. Doctors have to have more skills besides being smart. From this research we can learn that those students accustomed to working hard and who are motivated to follow a long education will succeed to become physicians. Do you know how to select med students please let me know in the comments.

Urlings-Strop, L., Stijnen, T., Themmen, A., & Splinter, T. (2009). Selection of medical students: a controlled experiment Medical Education, 43 (2), 175-183 DOI: 10.1111/j.1365-2923.2008.03267.x

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What Humor Style Do You Have?

Dr Shock — Mon, 01 Feb 2010 07:33:40 +0000

Did you know there is a sense of humor questionnaire? It’s called the Humor Styles Questionnaire and distinguishes between four styles of humor.

Affiliative, use of humor to amuse others and facilitate relationships
Self enhancing, use of humor to cope with stress and maintain a humorous outlook during times of difficulty
Aggressive, use of sarcastic, manipulative, put-down, or disparaging humor
Self-defeating, use of humor for excessive self-disparagement, ingratiation, or defensive denial

The first two positive styles are negatively correlated with anxiety and depression and positively correlated with self-esteem, extraversion, openness and agreeableness. The last two are negatively correlated with agreeableness and conscientiousness and positively correlated with neuroticism, hostility and aggression. But aside these correlations of more importance is the question: what does one of these styles tell you about the personality of the person with this distinct style pattern?

This was researched with a big five questionnaire (international personality item pool IPIP), the Rosenberg self-esteem scale and the humor styles questionnaire in 318 Australian participants of which 50% consisted of under and graduate university students and the remainder were chosen from the general population.

Four clusters of people were identified consisting of those who score: (1) above average on all of the styles, or (2) below average on all of the styles, or (3) above average on the positive styles (Affiliative and Self-enhancing), and below average on the negative styles (Aggressive and Self-defeating), or (4) above average on the negative styles and below average on the positive styles

Those participants who score high on average on all 4 styles are outgoing, impulsive and open to new experiences, those below average on all of the styles are restrained, not outgoing and well focused and organized. Recognizable, those with humor and those without are easily recognizable in these findings.

Those above average on the positive humor styles and below average on the negative humor styles are well balanced, low in anxiety, and positive towards themselves and others. They mostly use more lighthearted humor content, such as satire, irony,and philosophical humor.
Those in cluster 4, above average on the negative styles and below average on the positive styles are not open to new experiences and negative towards themselves as well as others:

Such people might use humor to defend against perceived threats to their self-image. Specifically, their use of aggressive humor can devalue those who they perceive as not valuing them. This could result in humor content which is sexist, racist, or sick

This research should be replicated and also focus more on other personality factors.

Galloway, G. (2010). Individual differences in personal humor styles: Identification of prominent patterns and their associates Personality and Individual Differences DOI: 10.1016/j.paid.2009.12.007

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Neuroanthropoly Wednesday Round Up #100 is up

Dr Shock — Fri, 29 Jan 2010 07:51:44 +0000

This time a weekly round up on Neuroanthropology with an enormous amount of links, I thought that’s were the #100 came from.
I especialy liked:

Power corrupts, but it corrupts only those who think they deserve it. Do you recognize this:

REPORTS of politicians who have extramarital affairs while complaining about the death of family values, or who use public funding for private gain despite condemning government waste, have become so common in recent years that they hardly seem surprising anymore.

Well that’s were this posts is about, enjoy.

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Neuron Connections Seen in 3-D on Science Daily with an amazing graphic.

A team of researchers from the Max Planck Institute of Biochemistry, in Germany, led by the Spanish physicist Rubén Fernández-Busnadiego, has managed to obtain 3D images of the vesicles and filaments involved in communication between neurons. The method is based on a novel technique in electron microscopy,…

At the end of the round up a lot of links to posts about video games and your brain, I probably missed some very nice posts so go and see for yourself at Neuroanthropology

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J.D. Salinger Died at the age of 91

Dr Shock — Thu, 28 Jan 2010 20:18:15 +0000

I can still remember his book The Catcher in the Rye. The English was hard to read at that age nevertheless I was instantly deeply moved by the book without knowing why it did, I was still fairly young (high school). After this successful book he has hardly written anything else. In his whole life he wrote one novel, three volumes of stories. The success of the book is explained as;

For decades that book was a universal rite of passage for adolescents, the manifesto of disenchanted youth.

The hero Holden Caulfield was the original angry but also sensitive young man in this book.

More about J.D. Salinger on TIME or on Wikipedia.

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