A double-blind comparative study of clozapine and risperidone in the management of severe chronic schizophrenia

OBJECTIVE

This prospective, double-blind, multicenter, parallel-group study compared the efficacy and safety of therapeutic doses of clozapine and risperidone in patients with severe chronic schizophrenia and poor previous treatment response.

METHOD

Male or female patients aged 18-65 years who met DSM-IV criteria for schizophrenia and study requirements for poor previous treatment response (N=273) were randomly assigned to double-blind treatment with either clozapine or risperidone administered over 12 weeks in increasing increments. The primary efficacy measures were the magnitude of improvement in Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression (CGI) scores. Adverse events were recorded throughout the study.

RESULTS

The magnitude of improvement in mean BPRS and CGI scores from baseline to end of the study was significantly greater in the clozapine group than in the risperidone group. Statistically significant differences in favor of clozapine were also seen for most of the secondary efficacy measures (Positive and Negative Syndrome Scale, Calgary Depression Scale, Psychotic Depression Scale, and Psychotic Anxiety Scale). The adverse event profile was similar for both treatment groups, with a lower risk of extrapyramidal symptoms in the clozapine group.

CONCLUSIONS

Clozapine showed superior efficacy over risperidone in this patient population. Both treatments were equally well tolerated as demonstrated through their adverse event profiles, although as expected clozapine was associated with a lower risk of extrapyramidal symptoms than risperidone.

Erfahrungen mit einer deutschsprachigen Version der SIB

Zusammenfassung: Die SIB (Severe Impairment Battery) wurde in den USA für die Untersuchung kognitiver Funktionen bei Schwerdementen entwickelt. Ziel der hier dargestellten Arbeit war die empirische Anwendung und Überprüfung einer deutschsprachigen Version der SIB hinsichtlich Objektivität, Reliabilität, Konstrukt-Validität und weiterer klinisch relevanter Aspekte. Eine Gruppe von 57 hospitalisierten dementen Patienten verschiedener Ätiologie (42ÿw, 15ÿm; Alter (SD) 83.0 (9.0) Jahre; mittlerer MMSE Score 5.6) wurde untersucht. Ergebnisse: Die SIB zeigte eine hohe Inter-Rater Reliabilität (0.99) und Interne Konsistenz (0.98). Die benötigte Testzeit lag zwischen 20 und 40 Minuten. Die Korrelation des SIB-Gesamtwertes mit dem MMSE-Score betrug 0.91, doch lieferte die SIB bei 11 von 14 Patienten, die im MMSE Nullwerte erreichten, noch Messergebnisse. Mit den kognitiven Dimensionen der NOSGER fanden sich hoch signifikante Korrelationen. Keine signifikanten Zusammenhänge bestanden psychopathologischen Merkmalen, und eine Unterscheidung verschiedener Demenzformen anhand der SIB-Ergebnisse war nicht möglich. Die deutschsprachige SIB kann als ökonomisches, zuverlässiges, empfindliches und valides Instrument zur Erfassung kognitiver Funktionen bei Schwerdementen empfohlen werden.

A retrospective study of diagnosis and management of mesenteric vein thrombosis

BACKGROUND

Mesenteric vein thrombosis (MVT) is an uncommon type of intestinal ischemia associated with significant mortality and morbidity because of its delay in diagnosis.

METHODS

A retrospective analysis of 9 patients treated surgically for MVT during 1982 to 1997 was performed.

RESULTS

Nine patients underwent surgical therapy for intestinal ischemia due to MVT. The most common presenting symptom was abdominal pain with bloody diarrhea in 3 patients; preoperative diagnosis of MVT was suspected in 2. Radiologic tests included plain roentgenograms, computed axial tomography, and ultrasound. Time to surgery ranged from 3 hours to 7 days after admission. All patients underwent resection of infarcted bowel with primary anastomosis and immediate postoperative anticoagulation. No patient underwent a second-look operation. The postoperative morbidity and mortality rates were 55% and 11%, respectively.

CONCLUSION

Diagnosis of intestinal ischemia from MVT is often delayed, and strong clinical suspicion and aggressive treatment are necessary in its management.

Efficacy of rivastigmine in dementia with Lewy bodies: a randomised, double-blind, placebo-controlled international study

BACKGROUND

Dementia with Lewy bodies is a common form of dementia in the elderly, characterised clinically by fluctuating cognitive impairment, attention deficits, visual hallucinations, parkinsonism, and other neuropsychiatric features. Neuroleptic medication can provoke severe sensitivity reactions in patients with dementia of this type. Many deficits in cholinergic neurotransmission are seen in the brain of patients with Lewy-body dementia; therefore, drugs enhancing central cholinergic function represent a rationally-based therapeutic approach to this disorder. Rivastigmine, a cholinesterase inhibitor, was tested in a group of clinically characterised patients with Lewy-body dementia.

METHODS

A placebo-controlled, double-blind, multicentre study was done in 120 patients with Lewy-body dementia from the UK, Spain, and Italy. Individuals were given up to 12 mg rivastigmine daily or placebo for 20 weeks, followed by 3 weeks rest. Assessment by means of the neuropsychiatric inventory was made at baseline, and again at weeks 12, 20, and 23. A computerised cognitive assessment system and neuropsychological tests were also used, and patients underwent close medical and laboratory safety analysis.

FINDINGS

Patients taking rivastigmine were significantly less apathetic and anxious, and had fewer delusions and hallucinations while on treatment than controls. Almost twice as many patients on rivastigmine (37, 63%), than on placebo (18, 30%), showed at least a 30% improvement from baseline. In the computerised cognitive assessment system and the neuropsychological tests, patients were significantly faster and better than those on placebo, particularly on tasks with a substantial attentional component. Both predefined primary efficacy measures differed significantly between rivastigmine and placebo. After drug discontinuation differences between rivastigmine and placebo tended to disappear. Known adverse events of cholinesterase inhibitors (nausea, vomiting, anorexia) were seen more frequently with rivastigmine than with placebo, but safety and tolerability of the drug in these mostly multimorbid patients were judged acceptable.

INTERPRETATION

Rivastigmine 6-12 mg daily produces statistically and clinically significant behavioural effects in patients with Lewy-body dementia, and seems safe and well tolerated if titrated individually.

Dementia with lewy bodies: findings from an international multicentre study

OBJECTIVES

To describe the baseline demographic, neuropsychiatric and neurological data of a large selected clinical sample of patients with dementia with Lewy Bodies (DLB) from an international multicentre trial with rivastigmine. To examine the usefulness of the Consensus Criteria for the diagnosis of DLB in different countries.

METHODS

Seventeen centres from Spain, the UK and Italy recruited patients diagnosed clinically as probable DLB according to recent Consensus Criteria (McKeith et al., 1996). A standard clinical protocol including inclusion/exclusion criteria, collection of demographic and medical data, cognitive (Mini Mental State Examination: MMSE), motor (Unified Parkinson's Disease Rating Scale: UPDRS) and neuropsychiatric (Neuropsychiatric Inventory: NPI) examinations, was applied after obtaining informed consent. Data were summarised and compared across countries with uni- and multivariate analyses.

RESULTS

One hundred and twenty patients were recruited: 56.7% males, mean (SD) age 73.9 (6.4) years, range 57 - 87 years. Sixty percent fulfilled all three core diagnostic features of DLB, and 40% only two ('parkinsonism' 92.4%, 'cognitive fluctuations' 89.1%, 'visual hallucinations' 77.3%). 'Systematised delusions' (46%) and 'repeated falls' (42%) were the most frequent supportive diagnostic features. There were no differences across countries in demographic, diagnostic or clinical features. Patients showed a wide range of psychopathology which was weakly correlated with cognitive impairment. Some mild extrapyramidal signs (EPS) were observed in most patients.

CONCLUSIONS

The Consensus Criteria for DLB can be consistently applied across many different sites for multicentre studies. 'Parkinsonism' and 'cognitive fluctuations' as core features and 'systematised delusions' and 'repeated falls' as supportive features are the most frequent diagnostic clues. Neuropsychiatric disturbances, in particular apathy, delusions, hallucinations and anxiety, and mild symmetric EPS are frequent in DLB and are only related weakly to cognitive impairment.

KRIT1 is mutated in hyperkeratotic cutaneous capillary-venous malformation associated with cerebral capillary malformation

Hyperkeratotic capillary-venous malformations (HCCVMs) are rare cutaneous lesions that occur in a small subgroup of patients with cerebral capillary malformation (CCM). CCMs cause neurological problems that range from headaches to life-threatening intracranial bleeding. CCMs and HCCVMs have a similar histopathological appearance of dilated capillary-venous channels. Genetic linkage of inherited CCMs has been established to three chromosomal loci, 3q25. 2-27, 7p13-15 and 7q21-22. The first mutations were identified in the CCM1 gene (located on 7q21-22), which encodes KRIT1 protein (KREV1 interaction trapped 1), presumably a membrane-bound protein with signalling activity. Although KRIT1 is known to interact with KREV1/RAP1A, a Ras-family GTPase, the exact function of KRIT1 in the formation of cerebral capillaries and veins is poorly understood. In this study, we screened five families with CCM for mutations in the KRIT1 gene. In one of the families, CCMs co-segregated with HCCVMs. We identified a KRIT1Delta(G103)mutation in this family, suggesting that this rare form of the condition is also caused by mutations in the CCM1 gene and that KRIT1 is probably important for cutaneous vasculature. Interestingly, this deletion introduces the earliest stop codon among identified mutations, suggesting a possible correlation between the molecular alteration and the cutaneous phenotype. Another novel mutation, KRIT1(IVS2+2(T-->C)), was found in a family with only cerebral capillary-venous malformations.

[Conviction as a basis for compliance and strategies for improving compliance]

The aim of the present study was to correlate statements made by 100 patients of an internal medicine ward regarding their compliance before hospitalization, with their personal knowledge of an convictions about their own pharmacotherapy. Data were collected in structured interviews of 9 questions carried out by a medical person not involved in current treatment. The patient sample (mean age +/- SE: 6.8 +/- 1.3 years) included 42 women and 58 men whose mean number of prescribed medications before hospitalization was 4.7 +/- o.22. Good treatment compliance was reported by 78% of the patients, while 13% admitted non- compliance. Knowledge about the drugs they had been prescribed ranged from perfect (30%) to none (34%) and was significantly different between compliers and non-compliers, with patients who know their medications at least by name being fairly compliant (p = 0.048). Independently of the statement about compliance, the patients used three main strategies to ensure regular intake of daily medication: visual aids (69%), coupling to a ritual (26%) or supervision by a third person (6%). Criteria such as gender, the number of prescribed medications, personal perseverance, or personal definition of the sense of the prescribed pharmacotherapy, or the arguments expected to be used by a physician when recommending a pharmacotherapy did not differ between compliers and non-compliers. Thus, compliance appears to have its roots mainly in the conviction level of each patient : intention will be transformed into action when deemed correct according to the individual's personal criteria. This may lead to both compliance and to non-compliance with medical recommendations. This study, which is based on patient reports, supports the conclusion that drug compliance may be enhanced by increasing patient's knowledge about their own pharmacotherapy and by having patients use specific strategies to guarantee regular daily intake of drugs. Prospective studies should therefore address the question of whether providing specific information according to a patient's convictions will untimately translate into improved compliance.

Intussusception in adults

Intussusception in adults is a rare entity that it is generally caused by definable intraluminal pathology. We report four cases of adult intussusception caused by lymphoma of the terminal ileum (2), an inflamed appendix (1) and a mucosal polyp (1). All presented with a variety of nonspecific and chronic symptoms, including abdominal pain, nausea and vomiting, consistent with partial small bowel obstruction. Only one patient had palpable masses in the abdomen. The most useful diagnostic radiological method was computed tomography (CT), which showed "target" lesions. The presence of the characteristic "target" lesion may obviate the need for further studies, including a barium enema. As in the cases reported here, treatment involves more than simple reduction; surgical resection is usually indicated.

Polygraphic sleep criteria as predictors of successful aging: an exploratory longitudinal study

BACKGROUND

A cohort of 57 elderly healthy volunteers (34 male, 23 female) was studied in a sleep laboratory on four consecutive nights when their average age was 63.5 +/- 3.7 years. Thirty subjects (20 male, 10 female) were assessed 14 years later; 21 had either died in the meantime or were very ill, and 6 did not participate for other reasons.

METHODS

Two operationalizations of successful aging were applied: survival in relatively good health (30 survivors vs. 21 nonsurvivors), and cognitive competence as assessed in the survivors by means of tests of cognitive function.

RESULTS

Whereas none of the sleep characteristics determined at baseline distinguished the survivors from the nonsurvivors, several parameters [REM (rapid eye movement) sleep latency, REM density, and NREM (non-REM) shifts] were significantly correlated with one or more measures of cognitive functioning at follow-up. These polygraphic sleep parameters also distinguished a subgroup of cognitively fully competent subjects from those who, according to their performance in tests of cognitive function, could be considered as mildly demented.

CONCLUSIONS

While the REM latency and density findings support the theory of a functional link between brain cholinergic activity, timing, and density of REM sleep and cognitive functioning, the positive association between the number of NREM shifts at baseline and cognitive performance 14 years later is difficult to explain. It is suggested that the findings of the present study, in particular the potential predictive value of REM latency and REM density for cognitive functioning in the old, need replication in other subject samples followed for similar time periods.

[X-chromosomal bulbospinal muscular atrophy (Kennedy syndrome)]

Two brothers with slowly progressive weakness and congenital nystagmus are presented. DNA analysis confirmed X-linked recessive bulbospinal muscular atrophy (XBSMA, Kennedy's disease) by demonstration of increased size of a CAG-triplet repeat on the androgen receptor gene on the X-chromosome. XBSMA is characterized by almost symmetrical muscular atrophy, weakness and fasciculations predominantly of bulbar, facial and proximal muscles of the extremities, with onset in the third to fifth decade. Tendon reflexes are depressed and pyramidal signs are absent. Sensory symptoms are clinically rare, but sensory nerve action potentials are frequently abnormal. Additional symptoms are important for differential diagnosis, and include postural tremor, gynecomastia, diabetes mellitus, testicular atrophy and impotence. Differentiation of this hereditary disorder from treatable conditions such as multifocal motor neuropathy or amyotrophic lateral sclerosis is essential. Though life expectancy is normal, patients become disabled in the course of the disease and need supportive care. Periodic testing for diabetes is recommended, and genetic counseling should be provided for patients and their relatives.

[Familial giant hemangiomas of the liver. Study of a family and review of the literature]

In this report we present for the first time strong evidence for autosomal-dominant inheritance of grant liver hemangiomas. Furthermore, we review the current literature about incidence, pathogenesis, clinics, as well as diagnostic and therapeutic aspects of LH. A large family of Italian origin is described where three female patients in three successive generations suffered from large symptomatic LH. In addition, two other female relatives exhibited asymptomatic LH on sonographic scans. The restriction of the disease to the female gender could be explained by a sex-dependent difference in penetrance or expressivity of a presumable "liver-hemangioma" gene, or by known proliferative factors such as female sex hormones. We also observed an increased incidence of adenomas of the thyroidea among members with or without LH of the presented family. This uncommon familial association has also not yet been described and its genetic aspects are discussed.

Early diagnosis of dementia via a two-step screening and diagnostic procedure

We propose a two-step process for the assessment of dementia using standardized instruments. The family physician performs a screening consisting of taking a medical history, gathering information from relatives and friends of the patient, and administering the combined Mini-Mental State Examination (MMSE) and Clock Drawing Test (CDT). Specialists examine patients with suspected dementia to confirm the diagnosis of dementia and, after a thorough differential diagnostic process, provide the family physician with recommendations for treatment. Specialists should perform neurological and psychiatric examinations, imaging (computer-assisted tomography [CT], magnetic resonance imaging [MRI]), and laboratory work-up. The Consortium to Establish a Registry for Alzheimer's Disease (CERAD) core neuropsychological battery is proposed to serve as a minimal data set that is internationally compatible. In addition, we recommend the Nurses' Observation Scale for Geriatric Patients (NOSGER) as a standard tool for functional assessment.

[Pyogenic liver abscess in children]

2 children with pyogenic liver abscesses were hospitalized during the past 2 years. A 6-year-old boy had high fever and hepatomegaly, and a large liver abscess was found in the right hepatic lobe. Streptococcus milleri was isolated from the pus. Treatment with a combination of prolonged drainage of the abscess and antibiotic therapy was successful. A 4-month-old girl who had prolonged fever was found to have osteomyelitis of 3 thoracic vertebrae and 2 liver abscesses in the right lobe. She was treated successfully with broad spectrum antibiotics. Additional workup revealed that she had chronic granulomatous disease.

Protocols to demonstrate slowing of Alzheimer disease progression. Position paper from the International Working Group on Harmonization of Dementia Drug Guidelines. The Disease Progression Sub-Group

Two suggested clinical trial designs for assessing progression of Alzheimer disease are the randomized withdrawal design and the randomized start design. The most promising of these, the randomized start design, has the potential to demonstrate a delay in progression, but there remain problematic design, ethical, and statistical issues to be solved before the protocol can be used in a clinical trial. The development of biological markers of the disease process using neuroimaging or other measures also may provide a robust method of measuring disease progression and demonstrating the biological effect of a drug on the disease process.

[Significance of impartial assessment of geriatric brain diseases]

In addition to traditional psychodiagnostic and neuropsychological methods used for assessing cognitive performance and its possible deterioration in the elderly, a number of instruments are available today that allow reliable and valid behavioural assessments to be made of geriatric patients' everyday behaviour. While rating of institutionalized geriatric patients usually focuses on the type and amount of nursing care needed, other areas of behaviour, such as activities of daily life (ADL) and instrumental ADL (IADL), memory, mood, social behaviour and disturbing behaviours are of primary interest in the case of aged individuals living in their own homes. The NOSGER (Nurses' observation scale for geriatric patients), which was introduced a few years ago, allows assessment of six important dimensions of behaviour; the scale can be easily and reliably used by professional nursing personnel as well as by untrained caregivers. The present paper describes the practical use of the instrument as well as possible graphic display of NOSGER findings; furthermore, normative values for five out of six NOSGER dimensions are given.

Category fluency is also predominantly affected in Swiss Alzheimer's disease patients

OBJECTIVES

To establish the comparative efficacy to differentiate between Swiss patients with dementia of the Alzheimer type (DAT) and elderly normal control subjects (NC) on two different verbal fluency tasks: category fluency and letter fluency.

MATERIAL AND METHODS

Fifty Swiss German DAT patients in the early stages of the disease and 50 matched normal control subjects were compared on letter and category fluency tasks.

RESULTS

DAT patients exhibited an overproportional impairment on category fluency as compared with letter fluency. Receiver operating characteristic curves (ROC) showed that category fluency correctly classified a significantly higher number of DAT patients and NC subjects (84%) than letter fluency (70%).

CONCLUSION

As similar findings have been described for English-speaking DAT patients, we conclude that deficiencies in category fluency are a general phenomenon, reflecting impaired structures of semantic knowledge occurring early in the course of Alzheimer's disease.

Striatal glucose metabolism and dopamine D2 receptor binding in asymptomatic gene carriers and patients with Huntington's disease

We used PET scans with the tracers [18F]fluorodeoxyglucose (FDG) and [11C]raclopride (RACLO) to study glucose metabolism and dopamine D2 receptor binding in the caudate nucleus and putamen of 18 carriers of the Huntington's disease gene mutation (10 asymptomatic subjects and eight untreated symptomatic Huntington's disease patients in an early disease stage). We also performed MRI scans and measured the bicaudate ratio (BCR) in the same subjects. Data were compared with those from nine mutation-negative members of Huntington's disease families and separate groups of age matched controls. The PET scans were repeated 1.5-3 years later in six of the asymptomatic gene carriers. Symptomatic Huntington's disease patients showed a marked reduction of FDG and RACLO uptake in the caudate nucleus and putamen and a significant increase of BCR. Asymptomatic mutation carriers revealed significant hypometabolism in the caudate nucleus and putamen. The RACLO binding was significantly decreased in the putamen. Decrements of caudate nucleus tracer uptake, particularly RACLO, correlated significantly with BCR increases in both symptomatic and asymptomatic gene carriers. In asymptomatic carriers, metabolic and receptor binding decreases were also significantly associated with the CAG repeat number but not with the individual's age. Discriminant function analysis correctly classified clinical and genetic status in 24 of 27 subjects on the basis of their striatal PET values (83% sensitivity and 100% specificity). Three asymptomatic mutation carriers were classified/grouped together with mutation-negative subjects, indicating that these individuals had normal striatal RACLO and FDG uptake. Follow-up PET data from gene-positive subjects showed a significant reduction in the mean striatal RACLO binding of 6.3% per year. Striatal glucose metabolism revealed an overall non significant 2.3% decrease per year. These data indicate that asymptomatic Huntington's disease mutation carriers may show normal neuronal function for a long period of life. These findings also suggest that it may be possible to predict when an asymptomatic gene carrier will develop clinical symptoms from serial PET measurements of striatal function.

Cystic fibrosis associated with neuronal intestinal dysplasia type B: a case report

The authors present the case of a newborn girl who had cystic fibrosis associated with neuronal intestinal dysplasia type B (NID-B). The association is rare but must be considered in the differential diagnosis of gastrointestinal problems in patients with cystic fibrosis. The present case elucidates the intestinal problems that can arise with this combination of diseases. Although the unusual association found in this patient could have been a random occurrence, the possibility of an NID-B determining gene localized on chromosome 7q should be considered.

Genetic heterogeneity in autosomal dominant pattern dystrophy of the retina

PURPOSE

Mutations in the retinal degeneration slow (RDS)/peripherin gene have been shown to be associated with pattern dystrophy of the retina (PDR) and other retinal dystrophies. The aim of our study was to confirm or exclude the RDS locus and the rhodopsin (RHO) locus as the disease causing locus in a large Swiss family affected with pattern dystrophy of the retina.

MATERIALS AND METHODS

A Swiss family with 14 members across 3 generations affected with PDR was examined. Eleven living family members were investigated using 6 markers surrounding the RDS and RHO loci.

RESULTS

Linkage to two possible candidate genes, the RDS gene on chromosome 6p and the rhodopsin gene on chromosome 3q, could be excluded.

CONCLUSIONS

The family provides evidence for genetic heterogeneity of PDR and is in agreement with heterogeneity in other retinal dystrophies. Further investigations are in progress to map the gene causing PDR in this family.

[Molecular genetic diagnosis and deletion analysis in Type I-III spinal muscular atrophy]

Autosomal recessive spinal muscular atrophy (SMA) is, after cystic fibrosis, the second most common fatal monogenic disorder. The disease is characterized by degeneration of anterior horn cells leading to progressive paralysis with muscular atrophy. Depending on the clinical type (Werdnig-Hoffmann = type I, intermediate form = type II, Kugelberg-Welander = type III), SMA causes early death or increasing disability in childhood. The SMA-critical region on the long arm of chromosome 5q13.1 contains many duplicated genes and polymorphisms. Recently, two presumptive SMA genes (survival motoneuron gene = SMN, and neuronal apoptosis inhibitory protein = NAIP) have been identified. Deletions involving critical regions of these genes are very often associated with SMA, and the extent of the deletions seems to correlate in part with disease severity. We have evaluated the diagnostic and prognostic value of molecular analysis in a large number of SMA patients. 57 patients and 78 healthy relatives were molecularly screened for deletions in the SMA critical region. We demonstrated homozygous deletions removing the SMN genes in over 90% of patients, whereas nearly 45% of patients exhibited NAIP gene deletions. Large deletions involving both genes on each chromosome are generally found in patients with severe SMA (Werdnig-Hoffman cases), while mildly affected Kugelberg-Welander cases frequently show only deleted SMN genes. Molecular classification based on combined deletion sizes, however, seems not to be exact, especially for the group with chronic SMA (type II and III). Direct DNA testing of patients in whom SMA is suspected is a highly reliable, fast, and noninvasive method. The ability to detect homozygous gene deletions in a high percentage of typical SMA patients will much improve genetic counselling and prenatal diagnosis in affected families.

Psychiatric symptoms and CAG expansion in Huntington's disease

The mutation responsible for Huntington's disease (HD) is an elongated CAG repeat in the coding region of the IT15 gene. A PCR-based test with high sensitivity and accuracy is now available to identify asymptomatic gene carriers and patients. An inverse correlation between CAG copy number and age at disease onset has been found in a large number of affected individuals. The influence of the CAG repeat expansion on other phenotypic manifestations, especially specific psychiatric symptoms has not been studied intensively. In order to elucidate this situation we investigated the relation between CAG copy number and distinct psychiatric phenotypes found in 79 HD-patients. None of the four differentiated categories (personality change, psychosis, depression, and nonspecific alterations) showed significant differences in respect to size of the CAG expansion. In addition, no influence of individual sex on psychiatric presentation could be found. On the other hand in patients with personality changes maternal transmission was significantly more frequent compared with all other groups. Therefore we suggest that clinical severity of psychiatric features in HD is not directly dependent on the size of the dynamic mutation involved. The complex pathogenetic mechanisms leading to psychiatric alterations are still unknown and thus genotyping does not provide information about expected psychiatric symptoms in HD gene carriers.