Metformin provides a statistically significant, but very modest reduction in BMI when combined with lifestyle interventions over the short term. A large trial is needed to determine the benefits to subgroups or impacts of confounders. In the context of other options for treating childhood obesity, metformin has not been shown to be clinically superior.

T rigeminal neuralgia (TN) is a pain syndrome characterized by severe, paroxysmal, lancinating facial pain. While many patients experience relief with carbamazepine or other drugs, many patients require surgery when their symptoms become refractory to medical therapy, or when they can no longer tolerate the medications.1 Surgical treatments such as neurectomy have targeted peripheral branches of the nerve external to the skull, and percutaneous ablative therapies have been directed at the gasserian ganglion using techniques such as radiofreabbreviatioNs BAEP = brainstem auditory evoked potential; BNI = Barrow Neurological Institute; BPI = Brief Pain Inventory; GKS = Gamma Knife surgery; HR = hazard ratio; IN = internal neurolysis; MVD = microvascular decompression; NVC = neurovascular compression; PSR = partial sensory rhizotomy; QOL = quality of life; REZ = root entry zone; RFL = radiofrequency gangliolysis; TN = trigeminal neuralgia. . Chart reviews and telephone interviews were conducted to assess patient outcomes. Pain intensity was evaluated with the Barrow Neurological Institute (BNI) Pain Intensity scale, and the Brief Pain Inventory-Facial (BPIFacial) was used to assess general and face-specific activity. Pain-free survival and durability of successful pain relief (BNI pain scores of 1 or 2) were statistically evaluated with Kaplan-Meier analysis. Prognostic factors were identified and analyzed using Cox proportional hazards regression. results A total of 177 patients with Type 1 TN were identified. A subgroup of 27 was found to have no NVC on highresolution MRI/MR angiography or at surgery. These patients were significantly younger than patients with classic Type 1 TN. Long-term follow-up was available for 26 of 27 patients, and 23 responded to the telephone survey. The median follow-up duration was 43.4 months. Immediate postoperative results were comparable to MVD, with 85% of patients pain free and 96% of patients with successful pain relief. At 1 year and 5 years, the rate of pain-free survival was 58% and 47%, respectively. Successful pain relief at those intervals was maintained in 77% and 72% of patients. Almost all patients experienced some degree of numbness or hypesthesia (96%), but in patients with successful pain relief, this numbness did not significantly impact their quality of life. There was 1 patient with a CSF leak and 1 patient with anesthesia dolorosa. Previous treatment for TN was identified as a poor prognostic factor for successful outcome. coNclusioNs This is the first report of IN with meaningful outcomes data. This study demonstrated that IN is a safe, effective, and durable treatment for TN in the absence of NVC. Pain-free outcomes with IN appeared to be more durable than radiofrequency gangliolysis, and IN appears to be more effective than stereotactic radiosurgery, 2 alternatives to posterior fossa exploration in cases of TN without NVC. Given the younger age distribution of patients in this group, consideration should be given to performing IN as an initial treatment. Accru...

Fossil records showing trephination in the Stone Age provide evidence that humans have sought to influence the mind through physical means since before the historical record. Attempts to treat psychiatric disease via neurosurgical means in the 20th century provided some intriguing initial results. However, the indiscriminate application of these treatments, lack of rigorous evaluation of the results, and the side effects of ablative, irreversible procedures resulted in a backlash against brain surgery for psychiatric disorders that continues to this day. With the advent of psychotropic medications, interest in invasive procedures for organic brain disease waned. Diagnosis and classification of psychiatric diseases has improved, due to a better understanding of psychiatric patho-physiology and the development of disease and treatment biomarkers. Meanwhile, a significant percentage of patients remain refractory to multiple modes of treatment, and psychiatric disease remains the number one cause of disability in the world. These data, along with the safe and efficacious application of deep brain stimulation (DBS) for movement disorders, in principle a reversible process, is rekindling interest in the surgical treatment of psychiatric disorders with stimulation of deep brain sites involved in emotional and behavioral circuitry. This review presents a brief history of psychosurgery and summarizes the development of DBS for psychiatric disease, reviewing the available evidence for the current application of DBS for disorders of the mind.