Electroconvulsive therapy for treatment of late-onset obsessive compulsive disorder

An 81-year-old female with no previous psychiatric history presented with late-onset obsessive compulsive disorder following an acute right macular hemorrhage and loss of vision. Following a thorough organic screen to exclude a physical cause, various high doses of selective serotonin reuptake inhibitors were tried with no therapeutic benefit. The patient had significant remission of her symptoms following a course of electroconvulsive therapy.

Impact of autologous hematopoetic stem cell transplantation on the quality of life of patients with multiple sclerosis

OBJECTIVE: To evaluate the impact of autologous hematopoetic stem cell transplantation (autoHSCT) in the health related quality of life (HRQL) in patients with multiple sclerosis. METHOD: The sample consisted of 34 patients, over 18 years old, treated at a University Hospital in the state of São Paulo, Brazil. For data collection MOS SF-36 and EDSS scales were applied at three time points: admission of the patient, hospital discharge and 1 year posttransplantation. RESULTS: 27 patients (79%) showed stabilization or neurological improvement 1 year posttransplantation. At this time point, there was statistically significant improvement in all domains of the HRQoL. When EDSS scores were correlated with the domains of the MOS SF-36 scale, statistically significant correlations were found with physical functioning at the three time points analysed. CONCLUSION: In spite of the high risk of complications of the procedure, the HSCT had positive impact in the health related quality of life.

Focal intracranial infections due to Actinomyces species in immunocompetent patients: diagnostic and therapeutic challenges

OBJECTIVE

Actinomyces spp. are often underestimated as causes of central nervous system infection because they are not looked for routinely and are difficult to detect. We try to determine the optimal management of these problematic intracranial infectious diseases in neurosurgical practice.

METHODS

Five cases of intracranial suppurations due to Actinomyces spp. treated between December 2007 and February 2009 are reported. The relevant clinicobacteriologic features and treatment outcomes are analyzed.

RESULTS

There were two brain abscesses, two subdural empyemas, and one frontal sinus pyomucocele with intracranial extension. Among them, three cases were previously operated and two patients were previously treated for otorhinolaryngeal infection. All cases were immunocompetent. In addition to Actinomyces sp., three patients had coinfectious bacteria (Pseudomonas aeruginosa, Staphylococcus warneri, and Escherichia coli). Complete resolution of the infection was achieved by means of aggressive surgical treatment and relatively short course of antibiotic therapy with a full recovery.

CONCLUSION

Actinomycotic focal cerebral infections may occur with greater frequency than previously recognized. Polymicrobial bacteria may be seen. This rare anaerobic organism should be considered in patients with a history of head trauma, previous surgery, or otorhinolaryngeal infection who present with a long duration of neurologic symptoms with or without an accompanying fever. Patients may be candidates for surgical debridement with relative shorter term of antibiotic therapy (ciprofloxacin).

Quantification of monosaccharides through multiple-reaction monitoring liquid chromatography/mass spectrometry using an aminopropyl column

A simple, sensitive, and reproducible quantitative liquid chromatography/tandem mass spectrometry (LC/MS/MS) method was designed for the simultaneous quantification of monosaccharides derived from glycoprotein and blood serum using a multiple-reaction monitoring (MRM) approach. Sialic acids and neutral monosaccharides were efficiently separated using an amino-bonded silica phase column. Neutral monosaccharide molecules were detected as their aldol acetate anion adducts [M + CH(3)CO(2)](-) using electrospray ionization in negative ion MRM mode, while sialic acids were detected as deprotonated ions [M-H](-). The new method did not require a reduction step, and exhibited very high sensitivity to carbohydrates with limits of detection of 1 pg for the sugars studied. The linearity of the described approach spanned over three orders of magnitude (pg to ng). The method was validated for monosaccharides originating from N-linked glycans attached to glycoproteins and glycoproteins found in human blood serum. The method effectively quantified monosaccharides originating from as little as 1 microg of glycoprotein and 5 microL of blood serum. The method was robust, reproducible, and highly sensitive. It did not require reduction, derivatization or postcolumn addition of reagents.

Quality of life and psychological problems in patients undergoing neurological rehabilitation

Aim:

To assess the quality of life (QoL) and prevalence of psychological problems (PP) in patients with neurological illness, and their correlation with functional abilities.

Materials and Methods:

Prospective cross-sectional study conducted in the neurological rehabilitation unit of tertiary research hospital in 30 consecutive hospitalized patients (21 men), age 16-55 years (34.63±11.87).

Outcome Measure:

WHOQoL-BREF was used to assess QoL. The prevalence of PP was recorded using Hospital Anxiety Depression Scale (HADS) and General Health Questionnaire (GHQ-12). QoL and HADS scores were correlated with functional abilities using mean Barthel Index (BI) Score.

Results:

The duration of illness was three to 30 months (10.63±7.83) and their primary diagnoses were stroke 12, traumatic spinal cord injury seven and non-traumatic spinal cord lesion 11. Twenty-two patients qualified for GHQ-12 caseness, with 15 patients having distress (score ≥15) and seven having severe problem and psychological distress (score≥20). Twenty five patients had abnormal anxiety and 17 had abnormal depression on HADS (abnormal = 8-21), with moderate to severe anxiety and depression (scores≥11) in nine and three patients respectively. The mean WHOQoL-BREF transformed scores (on WHOQoL 0-100 scale) were (38.83±8.02), (50.76±9.79), (48.53±18.46) and (49.13±10.63) in physical, psychological, social, and environmental domains respectively. The social domain of QoL had significant correlation (P<.05) with functional abilities.

Conclusion:

Patients with neurological disorders requiring inpatient rehabilitation have impaired QoL that affects all domains of life. There is high prevalence of psychological problems, including anxiety and depression. The social domain of QoL adversely affected functional abilities, but the correlation between PP and functional abilities was insignificant.

Caregiver Burden and Quality of Life of Older Persons With Stroke

This article reports a preliminary investigation in India of the association between caregiver burden and quality of life (QOL) in older persons with stroke after controlling for disability, depression, and sociodemographic factors. A cross-sectional analysis was carried out with 46 stroke patients attending a community hospital in India. The primary outcome variable was patient QOL assessed using the World Health Organization Quality of Life questionnaire–short form (WHOQOL-Bref). The primary explanatory variable was caregiver burden, assessed using the Zarit Inventory. Patient economic dissatisfaction ( F = 6.12, p = .04), patient depression ( F = 20.8, p < .001), and caregiver burden ( F = 7.36, p = .009) were found to be associated with lower patient QOL. Caregiver burden was independently associated with lower patient QOL after controlling for patient depression, disability, and economic dissatisfaction (standardized B coefficient = −0.28, p = .03). The level of caregiver burden was a significant correlate of QOL after stroke. Implications for future studies and practice are discussed.

Involvement of PPAR-gamma in curcumin-mediated beneficial effects in experimental dementia

The present study was undertaken to investigate the possible mechanism of curcumin-mediated beneficial effects in memory deficits associated with experimental dementia. Dementia was induced in Swiss albino mice by administering streptozotocin (3 mg kg(-1)) intracerebroventricularly on first and third day. Morris water maze test was employed to assess learning and memory of the animals. Biochemical analysis of brain homogenate was performed to assess brain acetyl cholinesterase (AChE) activity and total oxidative stress. Streptozotocin (STZ) produced a significant decrease in water maze performance of mice indicative of impairment in spatial reference memory. Curcumin (20 mg/kg p.o. daily for 14 days) successfully attenuated STZ-induced memory deficits. Higher levels of brain AChE activity and oxidative stress were observed in STZ-treated animals, which were significantly attenuated by curcumin. Furthermore, the noted beneficial effect of curcumin on STZ-induced dementia was significantly abolished by pretreatment with PPAR-gamma receptor antagonist bisphenol-A-diglycidyl ether, i.e., BADGE (30 mg/kg intraperitoneally (i.p.)). It may be concluded that the beneficial effects of curcumin are mediated through the activation of PPAR-gamma receptors.

Novel insights on diagnosis, cause and treatment of diabetic neuropathy: focus on painful diabetic neuropathy

Diabetic neuropathy is common, under or misdiagnosed, and causes substantial morbidity with increased mortality. Defining and developing sensitive diagnostic tests for diabetic neuropathy is not only key to implementing earlier interventions but also to ensure that the most appropriate endpoints are employed in clinical intervention trials. This is critical as many potentially effective therapies may never progress to the clinic, not due to a lack of therapeutic effect, but because the endpoints were not sufficiently sensitive or robust to identify benefit. Apart from improving glycaemic control, there is no licensed treatment for diabetic neuropathy, however, a number of pathogenetic pathways remain under active study. Painful diabetic neuropathy is a cause of considerable morbidity and whilst many pharmacological and nonpharmacological interventions are currently used, only two are approved by the US Food and Drug Administration. We address the important issue of the 'placebo effect' and also consider potential new pharmacological therapies as well as nonpharmacological interventions in the treatment of painful diabetic neuropathy.

Associations between sleep disturbance and primary headaches: the third Nord-Trøndelag Health Study

The aim of the study was to evaluate the association between sleep disturbance and headache type and frequency, in a random sample of participants in the third Nord-Trøndelag Health Survey. The headache diagnoses were set by neurologists using the ICHD-2 criteria performing a semi structured face-to-face interview. Sleep problems were measured by the two validated instruments Karolinska Sleep Questionnaire (KSQ) and Epworth Sleepiness Scale (ESS). Among 297 participants, 77 subjects were headache-free, whereas 135 were diagnosed with tension-type headache (TTH), 51 with migraine, and 34 with other headache diagnoses. In the multivariate analyses, using logistic regression, excessive daytime sleepiness, defined as ESS ≥ 10, was three times more likely among migraineurs compared with headache-free individuals (OR = 3.3, 95% CI 1.0–10.2). Severe sleep disturbances, defined as KSQ score in the upper quartile, was five times more likely among migraineurs (OR = 5.4, 95% CI 2.0–15.5), and three times more likely for subjects with TTH (OR = 3.3, 1.4–7.3) compared with headache-free individuals. Subjects with chronic headache were 17 times more likely to have severe sleep disturbances (OR = 17.4, 95% CI 5.1–59.8), and the association was somewhat stronger for chronic migraine (OR = 38.9, 95% CI 3.1–485.3) than for chronic TTH (OR = 18.3, 95% CI 3.6–93.0). In conclusion, there was a significant association between severe sleep disturbances and primary headache disorders, most pronounced for those with chronic headache. Even though one cannot address causality in the present study design, the results indicate an increased awareness of sleep problems among patients with headache.

A comparison of computed tomography and magnetic resonance brain imaging in HIV-positive patients with neurological symptoms

We reviewed our practice in order to determine the optimum neuroimaging strategy for HIV-infected patients with acute neurological presentations between April 2007 and August 2008. Overall magnetic resonance imaging (MRI) detected cranial abnormalities in more than twice as many patients as did computed tomography (CT) (74% and 32%, n = 54 and 38, respectively). Replacement of CT by first-line MRI for all patients would have required an additional 16 MRI scans, although at a saving of 38 CT scans. Our study highlights the importance of first-line MRI brain imaging in HIV patients with neurological symptoms and reinforces the need for early transfer of patients from centres that do not have rapid access to (or expert interpretation of) MRI scanning, to an appropriate HIV specialist centre.

Calcaneal osteomyelitis presenting with acute tarsal tunnel syndrome: a case report

INTRODUCTION

Cases of acute tarsal tunnel syndrome are rare. To the best of our knowledge, we describe the only reported case of acute posterior tibial nerve compression resulting from adjacent haemotogenous pyogenic calcaneal osteomyelitis.

CASE PRESENTATION

A previously healthy 38-year-old Caucasian woman developed symptoms of acute tarsal tunnel syndrome in her right foot over a six-day period. No antecedent trauma or systemic symptoms were noted. Magnetic resonance imaging and bone scan imaging, followed by surgical decompression and bone biopsy confirmed a diagnosis of Staphylococcus aureus calcaneal osteomyelitis. Her pain and paraesthesia disappeared after the operation, while her inflammatory markers normalised during a 12-week course of antibiotics. After four years she has remained asymptomatic without any indication of recurrence.

CONCLUSION

This case is not just unique in describing osteomyelitis as a cause of tarsal tunnel syndrome, because haemotogenous calcaneal osteomyelitis is in itself a rare pathology. We recommend considering infection as a differential diagnosis in patients presenting with acute tarsal tunnel syndrome.

Pediatric psychogenic nonepileptic seizures: a study of assessment tools

The goal of this study was to identify assessment tools and associated behavioral domains that differentiate children with psychogenic nonepileptic seizures (PNES) from those with epilepsy. A sample of 24 children with PNES (mean age 14.0 years, 14 female), 24 children with epilepsy (mean age 13.6 years, 13 female), and their parents were recruited from five epilepsy centers in the United States. Participants completed a battery of behavioral questionnaires including somatization, anxiety, and functional disability symptoms. Children with PNES had significantly higher scores on the Childhood Somatization and Functional Disability Inventories, and their parents reported more somatic problems on the Child Behavior Checklist (CBCL). Depression, anxiety, and alexithymia instruments did not differentiate the groups. Measures of somatization and functional disability may be promising tools for differentiating the behavioral profile of PNES from that of epilepsy. Increased somatic awareness and perceived disability emphasize the similarity of PNES to other pediatric somatoform disorders.

An overview of Indian research in depression

Depression as a disorder has always been a focus of attention of researchers in India. Over the last 50-60 years, large number of studies has been published from India addressing various aspects of this commonly prevalent disorder. The various aspects studied included epidemiology, demographic and psychosocial risk factor, neurobiology, symptomatology, comorbidity, assessment and diagnosis, impact of depression, treatment related issues and prevention of depression in addition to the efficacy and tolerability of various antidepressants. Here, we review data on various aspects of depression, originating from India.

Screening for inborn errors of metabolism using automated electrospray tandem mass spectrometry: study in high-risk Indian population

OBJECTIVES

Tandem mass spectrometry is a major technological advance in the screening for inborn errors of metabolism. It has the advantage of sensitive and simultaneous multiple disease screening with minimal sample requirement. The diseases detected include aminoacidemias, fatty acid oxidation disorders, and organic acidemias.

DESIGN AND METHODS

Using automated electrospray tandem mass spectrometry we screened 3550, clinically selected, symptomatic children for inborn errors of metabolism by analyzing amino acids and acylcarnitines in dried blood filter-paper samples.

RESULTS

Among these, 113 (3.2%) children were identified with a metabolic disorder: 61 (54%) patients had amino acid disorders, 47 (41.6%) had organic acidemias, and 5 (4.4%) children had disorders of fatty acid oxidation. The diagnoses were further confirmed through clinical symptoms, and other biochemical studies.

CONCLUSIONS

These results show that inherited metabolic disorders are not rare in India, a rapidly developing country with a high birth rate and relatively frequent occurrence of consanguineous marriages.

Cardiac effects of carbamazepine treatment in childhood epilepsy

OBJECTIVE

Hypotension, bradycardia, and atrioventricular block are well-known cardiovascular effects of carbamazepine (CBZ). However, direct effects of CBZ on ventricular functions have been rarely encountered. We investigated the effect of CBZ on ventricular functions in pediatric patients without previous cardiac disease to determine whether CBZ causes ventricular dysfunction or electrocardiographic changes in therapeutic doses in children.

METHODS

The study includes 40 patients (31 boys, 9 girls) with epilepsy who had been treated with carbamazepine. Electroencephalography, electrocardiography, echocardiography, and cranial imaging were performed on all patients before treatment and were repeated at the end of the third and 12th months of treatment. The systolic and diastolic thickness of the interventricular septum and the posterior wall of the left ventricle and the systolic and diastolic diameter of the left ventricle were measured during M-mode investigation. The end-systolic and end-diastolic volumes (mL), the stroke volume (mL), fractional shortening (FS), (%) and ejection fraction (EF) (%) measurements were obtained from the computer on the echocardiography device.

RESULTS

In 1-year follow-up, no electrocardiographic abnormalities were detected. The FS and EF values showing left ventricular function did not show a significant difference (P > 0.05).

CONCLUSIONS

CBZ seems to be a safe drug in pediatric epileptic patients without any preexisting cardiac disease. We suggest that the risk factors should be defined and followed-up regarding cardiac function when treatment is initiated in groups with risk factors.

Human angiostrongyliasis outbreak in Dali, China

Background

Several angiostrongyliasis outbreaks have been reported in recent years but the disease continues to be neglected in public health circles. We describe an outbreak in Dali, southwest China in order to highlight some key problems for the control of this helminth infection.

Methodology/Principal Findings

All available medical records of suspected angiostrongyliasis patients visiting hospitals in Dali in the period 1 October 2007–31 March 2008 were reviewed, and tentative diagnoses of varying strengths were reached according to given sets of criteria. Snails collected from local markets, restaurants and natural habitats were also screened for the presence of Angiostrongylus cantonensis. A total of 33 patients met criteria for infection, and 11 among them were classified as clinically confirmed. An additional eight patients were identified through a surveillance system put in operation in response to the outbreak. The epidemic lasted for 8 months with its peak in February 2008. Of the 33 patients, 97.0% complained of severe headache. 84.8% patients had high eosinophil cell counts either in the peripheral blood or in cerebrospinal fluid (CSF). Three-quarters of the patients were treated with a combination of albendazole and corticosteroids, resulting in significantly improved overall conditions. Twenty-two patients reported the consumption of raw or undercooked snails prior to the onset of the symptoms, and approximately 1.0% of the Pomacea canaliculata snails on sale were found to be infected with A. cantonensis. The snails were also found in certain habitats around Dali but no parasites were detected in these populations.

Conclusions/Significance

The import and sale of infected P. canaliculata is the likely trigger for this angiostrongyliasis outbreak. Awareness of angiostrongyliasis must be raised, and standardized diagnosis and treatment are needed in order to provide clinicians with a guide to address this disease. Health education campaigns could limit the risk, and a hospital-based surveillance system should be established in order to detect future outbreaks.

Angiostrongyliasis, caused by the rat lungworm Angiostrongylus cantonensis, is a potentially fatal food-borne disease. It is endemic in parts of Southeast Asia, the Pacific Islands, Australia, and the Caribbean. Outbreaks have become increasingly common in China due to the spread of efficient intermediate host snails, most notably Pomacea canaliculata. However, infections are difficult to detect since the disease has a rather long incubation period and few diagnostic clinical symptoms. Reliable diagnostic tests are not widely available. The described angiostrongyliasis epidemic in Dali, China lasted for eight months. Only 11 of a total of 33 suspected patients were clinically confirmed based on a set of diagnostic criteria. Our results demonstrate that the rapid and correct diagnosis of the index patient is crucial to adequately respond to an epidemic, and a set of standardized diagnostic procedures is needed to guide clinicians. Integrated control and management measures including health education, clinical guidelines and a hospital-based surveillance system, should be implemented in areas where snails are a popular food item.

Nanostructured peptide fibrils formed at the organic-aqueous interface and their use as templates to prepare inorganic nanostructures

Formation of fibril-type nanostructures of the Alzheimer's beta-amyloid diphenylalanine (l-Phe-l-Phe, FF) at the organic-aqueous interface and the factors affecting their structures have been investigated. Such nanostructures are also formed by bovine serum albumin and bovine pancreas insulin. The concentration of the precursor taken in the aqueous layer plays an important role in determining the morphology of the nanostructures. The addition of curcumin to the organic layer changes the structure of the self-assembled one-dimensional aggregates of diphenylalanine. By coating the diphenylalanine dipeptide fibrils with appropriate precursors followed by calcination in air, it has been possible to obtain one-dimensional nanostructures of inorganic materials.

High prevalence of infantile encephalitic beriberi with overlapping features of Leigh's disease

Infantile encephalitic beriberi (IEBB) is a rare form of thiamine deficiency and is poorly described. A proportion of Leigh's disease (LD) patients have similar clinical picture and response to thiamine as beriberi, leading to confusion in diagnosis and management. Data on IEBB and LD is scarce and status of thiamine deficiency in India is controversial. We report several infants with life-threatening respiratory and central nervous system symptoms that overlap between IEBB and LD. Majority had low erythrocyte transketolase levels and responded dramatically to thiamine supplementation suggesting a diagnosis of IEBB. However, presence of characteristic lesions on brain imaging and residual damage in several patients on follow-up does not rule out LD completely. Our study highlights the importance of thiamine deficiency in India, especially in the breast-feds and its overlapping features with LD. Awareness of this common mode of presentation may save patients' lives by early diagnosis and timely thiamine supplementation.

Intracranial Aspergilloma in Immunocompetent Patients Successfully Treated with Radical Surgical Intervention and Antifungal Therapy – Case Series

Introduction: Aspergillosis of the central nervous system is an uncommon infection, mainly occurring in immunocompromised patients with a high mortality. Surgical excision of the intracranial lesion combined with oral voriconazole has been proposed to improve the outcome in immunocompromised patients. Itraconazole has been considered not to be effective because of poor penetration into the brain tissue. We report the long-term outcome of 3 cases of intracranial aspergilloma in immunocompetent patients who were successfully treated with radical surgery combined with oral itraconazole. Materials and Methods: This is a retrospective study in which chronic invasive intracranial aspergilloma was successfully treated in 3 apparently immunocompetent patients and followed-up for more than 5 years. Results: Near complete or radical surgical removal of this localised chronic invasive intracranial aspergilloma whenever possible is the definitive treatment. When combined with the oral antifungal drug itraconazole, the management regimen is effective in achieving near complete long-term cure of more than 5 years. Oral itraconazole 200 mg twice daily should be given for a prolonged period of at least 6 months. Conclusion: In chronic invasive intracranial aspergilloma in an immunocompetent patient, it was suggested that radical excision of the intracranial aspergilloma combined with oral antifungal drug belonging to triazole group that can be either itraconazole or voriconazole given for a period of 6 months was likely to improve the long-term outcome. Key words: Central nervous system aspergillosis, Aspergilloma, Itraconazole, Voriconazole

Psychosocial, demographic, and treatment-seeking strategic behavior, including faith healing practices, among patients with epilepsy in northwest India

The data on sociocultural, demographic, and psychosocial aspects and types of treatment strategies adopted by families of patients with epilepsy in northwestern India were collected by the interview schedule method from 400 patients (200 idiopathic and 200 symptomatic) at the outpatient department of the Neurology and Epilepsy Clinic of the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Epilepsy was classified as idiopathic or symptomatic on the basis of clinical tests (EEG, CT scan, and MRI). It was observed that socioeconomic factors had no bearing on epilepsy in the present sample. Early onset, that is, before 20 years of age, reduced the chances of patients' finding a spouse among those who disclosed the disease information, thereby impacting the nuptial and fertility rates of patients with epilepsy. The present sample of patients was well informed about and sensitized to the efficacy of the modern system of medicine, as 80% of patients sought medical treatment on the very same day as or within a week of onset of seizures. The data were compatible with the framed hypothesis that well-being and safety of the patient would override the stigma burden factor, as 94% of the affected families made no attempt to hide the disease from their neighbors, friends, and colleagues, and teachers of the affected patients. Surprisingly, only 7.5% of the families admitted that they consulted a faith healer. Families did adopt some culturally prevalent methods to control involuntary movements during seizures. It can be concluded that trust in faith healers exists strongly as an undercurrent, but is not overtly admitted by the majority of patients. Some families concurrently visited modern hospitals and occult healers seeking a cure for the disease. The fear of having a child with epilepsy or other abnormalities discouraged married patients from becoming pregnant after developing epilepsy.

Chronic Tuberculous Retropharyngeal Abscess Due to Vertebral Tuberculosis with Associated Calvarial Tuberculosis

The occurrence of chronic tuberculous retropharyngeal abscess and calvarial tuberculosis is rare, even in isolated form. Chronic tuberculous retropharyngeal abscess is usually due to vertebral tuberculosis in adults. Calvarial tuberculosis is a rare manifestation of extra-pulmonary tuberculosis with limited reports in medical literature. We describe a rare case of chronic tuberculous retropharyngeal abscess due to vertebral tuberculosis with associated calvarial tuberculosis.