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Okumura M, Mukai Y, Saika R, Takahashi Y. Association of severe hyposmia and frontal lobe dysfunction in patients with Parkinson's disease. J Neurol Sci 2024; 465:123205. [PMID: 39216171 DOI: 10.1016/j.jns.2024.123205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 07/05/2024] [Accepted: 08/25/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUNDS AND OBJECTIVES Severe hyposmia (SH) is a prodromal symptom of dementia associated with Parkinson's disease (PD) caused by Lewy bodies deposited in the limbic regions that connect the frontal and temporal lobes. We aimed to clarify the association between hyposmia and frontal lobe dysfunction (FLD) among patients with PD. METHODS Patients with PD and Hoehn & Yahr stage 1-3 at on-periods without apparent dementia were screened. FLD was defined as a score of ≤14 on the Frontal Assessment Battery (FAB). SH was defined as an average recognition threshold >4 in the T&T Olfactometer. For each subscore, a recognition score of ≥4 was defined as SH. We examined whether SH and its subscores were associated with FLD and evaluated which FAB subscore might be lower in PD patients with SH using Poisson regression analysis with a robust variance estimator. RESULTS We included 189 patients (median age, 68 years; 107 [57 %] male). FLD was observed in 53 (28 %) patients. Multivariable analysis showed that SH (PR 1.789, 95 % confidence intervals (CI) 1.115-2.872, p = 0.016) was associated with FLD. Regarding odor domains, only SH for fruity smells was associated with FLD (PR 1.970, 95 % CI 1.306-2.972, p = 0.001). Patients with SH had a higher subscore only for FAB-1 (similarity [conceptualization], p = 0.030), indicating linguistically mediated executive dysfunction. CONCLUSION In patients with PD, SH is associated with FLD, especially with linguistically mediated executive dysfunction. Particularly, SH for fruity smells may be a sensitive indicator of FLD.
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Affiliation(s)
- Motohiro Okumura
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8551, Japan.
| | - Yohei Mukai
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8551, Japan
| | - Reiko Saika
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8551, Japan
| | - Yuji Takahashi
- Department of Neurology, National Center Hospital, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8551, Japan
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Tang C, Sun R, Xue K, Wang M, Liang S, Kambey P, Shi M, Wu C, Chen G, Gao D. Distinct serum GDNF coupling with brain structural and functional changes underlies cognitive status in Parkinson's disease. CNS Neurosci Ther 2024; 30:e14461. [PMID: 37718594 PMCID: PMC10916445 DOI: 10.1111/cns.14461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/14/2023] [Accepted: 08/25/2023] [Indexed: 09/19/2023] Open
Abstract
AIM Aberrations in brain connections are implicated in the pathogenesis of Parkinson's disease (PD). We previously demonstrated that Glial cell-derived neurotrophic factor (GDNF) reduction is associated with cognition decline. Nonetheless, it is elusive if the pattern of brain topological connectivity differed across PD with divergent serum GDNF levels, and the accompanying profile of cognitive deficits has yet to be determined. METHODS We collected data on the participants' cognition, demographics, and serum GDNF levels. Participants underwent 3.0T magnetic resonance imaging, and we assessed the degree centrality, brain network topology, and cortical thickness of the healthy control (HC) (n = 25), PD-high-GDNF (n = 19), and PD-low-GDNF (n = 19) groups using graph-theoretic measures of resting-state functional MRI to reveal how much brain connectivity varies and its clinical correlates, as well as to determine factors predicting the cognitive status in PD. RESULTS The results show different network properties between groups. Degree centrality abnormalities were found in the right inferior frontal gyrus and right parietal lobe postcentral gyrus, linked with cognition scores. The two aberrant clusters serve as a potentially powerful signal for determining whether a patient has PD and the patient's cognition level after integrating with GDNF, duration, and dopamine dosage. Moreover, we found a significant positive relationship between the thickness of the left caudal middle frontal lobe and a plethora of cognitive domains. Further discriminant analysis revealed that the cortical thickness of this region could distinguish PD patients from healthy controls. The mental state evaluation will also be more precise when paired with GDNF and duration. CONCLUSION Our findings reveal that the topological features of brain networks and cortical thickness are altered in PD patients with cognitive deficits. The above change, accompanied by the serum GDNF, may have merit as a diagnosis marker for PD and, arguably, cognition status.
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Affiliation(s)
- Chuanxi Tang
- Department of Neurobiology, Xuzhou Key Laboratory of NeurobiologyXuzhou Medical UniversityXuzhouJiangsuChina
| | - Ruiao Sun
- Department of Neurobiology, Xuzhou Key Laboratory of NeurobiologyXuzhou Medical UniversityXuzhouJiangsuChina
| | - Ke Xue
- Department of Neurobiology, Xuzhou Key Laboratory of NeurobiologyXuzhou Medical UniversityXuzhouJiangsuChina
| | - Mengying Wang
- Department of Epidemiology and Biostatistics, School of Public HealthPeking University Health Science CenterBeijingChina
| | - Sijie Liang
- Department of RehabilitationThe Affiliated Hospital of Xuzhou Medical UniversityXuzhouJiangsuChina
| | - Piniel Alphayo Kambey
- Department of Neurobiology, Xuzhou Key Laboratory of NeurobiologyXuzhou Medical UniversityXuzhouJiangsuChina
| | - Mingyu Shi
- Department of Neurobiology, Xuzhou Key Laboratory of NeurobiologyXuzhou Medical UniversityXuzhouJiangsuChina
| | - Changyu Wu
- School of Medical ImagingXuzhou Medical UniversityXuzhouJiangsuChina
| | - Gang Chen
- Department of NeurologyShuyang Hospital of Traditional Chinese MedicineSuqianJiangsuChina
| | - Dianshuai Gao
- Department of Neurobiology, Xuzhou Key Laboratory of NeurobiologyXuzhou Medical UniversityXuzhouJiangsuChina
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Fan M, Li Q, Yang T, Yang Y, Chen Z, Xuan G, Ruan Y, Sun S, Wang M, Chen X, Huang Y, Yang Z, Wang Y. Effect of Multimodal Intervention in Individuals with Mild Cognitive Impairment: A Randomized Clinical Trial in Shanghai. J Alzheimers Dis 2024; 101:235-248. [PMID: 39031354 PMCID: PMC11380217 DOI: 10.3233/jad-231370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2024]
Abstract
Background Previous trials have indicated that multimodal training could improve cognitive functions and moods in individuals with mild cognitive impairment (MCI). However, evidence was mainly obtained from studies in high-income countries. Objective This trial aims to investigate the efficacy, safety, and potential mechanism of a multimodal intervention on cognitive function in individuals with MCI living in a community. Methods In this single-blind, randomized controlled trial, 120 participants with MCI were randomly assigned to either the intervention group or the control group. The intervention group received the multimodal intervention, while the control group received regular health education. Neuropsychological tests and magnetic resonance imaging (MRI) were conducted at baseline and after the 12-week intervention. Results Fifty-nine and fifty-seven participants respectively in the intervention and control groups completed the trial. The intervention group shown improvements in primary outcome, Mini-Mental State Exam (MMSE) total score (mean difference -0.96, 95% CI [-1.58, -0.34], p = 0.003), and secondary outcomes: MMSE recall (-0.39, 95% CI [-0.71, -0.07], p = 0.019), MMSE language (-0.26, 95% CI [-0.44, -0.07], p = 0.007), Auditory Verbal Learning Test instantaneous memory (-3.30, 95% CI [-5.70, -0.89], p = 0.008), Digit Symbol Substitution Test total score (-2.91, 95% CI [-5.67, -0.15], p = 0.039), digit span forwards (-1.25, 95% CI [-1.93, -0.56], p < 0.001), and Digit Span Test (-1.33, 95% CI [-2.33, -0.34], p = 0.009) compared to the control group. Improvements were observed in structural and functional connectivity related to language, concentration, executive function, memory, and recall functioning via MRI in the intervention group. Conclusions The multimodal intervention improved cognitive function in individuals with MCI in cognitive performance and neuroimaging.
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Affiliation(s)
- Meixiang Fan
- Department of General Medicine, Huashan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Qingfeng Li
- Shanghai Mental Health Center, Shanghai Jiao Tong University, Shanghai, China
| | - Tingting Yang
- Shanghai Center for Clinical Laboratory, Shanghai, China
| | - Yinghua Yang
- Shanghai Center for Clinical Laboratory, Shanghai, China
| | - Zhihua Chen
- Medicine-Mental Health Center of Minhang District, Shanghai, China
- Minhang Branch, School of Public Health, Fudan University, Shanghai, China
| | - Guo Xuan
- Medicine-Mental Health Center of Minhang District, Shanghai, China
- Minhang Branch, School of Public Health, Fudan University, Shanghai, China
| | - Ye Ruan
- Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
| | - Shuangyuan Sun
- Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
| | - Meng Wang
- School of Public Health, Fudan University, Shanghai, China
| | - Xiaoli Chen
- School of Public Health, Fudan University, Shanghai, China
| | - Yanyan Huang
- Department of General Medicine, Huashan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
- Tianqiao and Chrissy Chen Institute Clinic Translational Research Center, Shanghai, China
- Department of Geriatrics, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhi Yang
- Shanghai Key Laboratory of Psychotic Disorders, Shanghai Mental Health Center, Institute of Psychological and Behavioural Science, Shanghai Jiao Tong University, Shanghai, China
- Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
| | - Ying Wang
- School of Public Health, Fudan University, Shanghai, China
- Key Laboratory of Health Technology Assessment, National Health and Family Planning Commission of the People's Republic of China, Fudan University, Shanghai, China
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Pachi I, Papadopoulos V, Koros C, Simitsi AM, Bougea A, Bozi M, Papagiannakis N, Soldatos RF, Kolovou D, Pantes G, Scarmeas N, Paraskevas G, Voumvourakis K, Papageorgiou SG, Kollias K, Stefanis N, Stefanis L. Comprehensive Evaluation of Psychotic Features and Their Clinical Correlates in Early Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2023; 13:1185-1197. [PMID: 37840503 PMCID: PMC10657660 DOI: 10.3233/jpd-230056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Some reports suggest that psychotic features may occur in the early stages of Parkinson's disease (PD), but sensitive tools have not been utilized. OBJECTIVE The aim was to evaluate the presence of psychotic symptoms using detailed scales and to assess the association with clinical characteristics. METHODS Healthy controls and patients within three years of PD onset were recruited. Participants were examined for psychotic symptoms using two different instruments: the Comprehensive Assessment of At-Risk Mental States (CAARMS) and a 10 question PD specific psychosis severity scale (10PDQ). In the PD group, medication use, motor and non-motor symptoms were documented. RESULTS Based on CAARMS and 10PDQ scales, psychotic features were present in 39% (27/70) of patients and 4% (3/74) of controls. The prevalence of passage hallucinations and illusions was significantly higher in PD compared to the control group. The presence of PD-associated psychotic features was not significantly affected by medication, motor severity or global cognitive status. Higher prevalence of overall non-motor manifestations, REM sleep behavior disorder (RBD) and depressive symptoms was significantly associated with the manifestation of psychotic features in PD [(adjusted OR:1.3; 95% CI:1.1-1.6; p = 0.003), (adjusted OR:1.3; 95% CI:1.0-1.6; p = 0.023), and (adjusted OR:1.2; 95% CI:1.0-1.4;p = 0.026)]. CONCLUSIONS Psychotic phenomena mainly of minor nature are highly common in early PD. Cumulative non-motor symptoms, RBD and depressive features are associated with the presence of psychotic symptoms in this non-demented, early-stage PD population. More studies are needed to clarify the mechanisms that contribute to the onset of psychotic features in early PD.
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Affiliation(s)
- Ioanna Pachi
- 1 Department of Neurology, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vassilis Papadopoulos
- 1 Department of Neurology, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Christos Koros
- 1 Department of Neurology, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Athina Maria Simitsi
- 1 Department of Neurology, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Bougea
- 1 Department of Neurology, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Bozi
- 2 Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikos Papagiannakis
- 1 Department of Neurology, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Rigas Filippos Soldatos
- 1 Department of Neurology, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitra Kolovou
- 1 Department of Neurology, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George Pantes
- 1 Department of Neurology, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Scarmeas
- 1 Department of Neurology, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Taub Institute for Research in Alzheimer’s Disease and the Aging Brain, Columbia University, New York, NY, USA
| | - Georgios Paraskevas
- 2 Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Voumvourakis
- 2 Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Sokratis G. Papageorgiou
- 1 Department of Neurology, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Kollias
- 1 Department of Psychiatry, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikos Stefanis
- 1 Department of Psychiatry, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Leonidas Stefanis
- 1 Department of Neurology, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Pezzoli S, Sánchez-Valle R, Solanes A, Kempton MJ, Bandmann O, Shin JI, Cagnin A, Goldman JG, Merkitch D, Firbank MJ, Taylor JP, Pagonabarraga J, Kulisevsky J, Blanc F, Verdolini N, Venneri A, Radua J. Neuroanatomical and cognitive correlates of visual hallucinations in Parkinson's disease and dementia with Lewy bodies: Voxel-based morphometry and neuropsychological meta-analysis. Neurosci Biobehav Rev 2021; 128:367-382. [PMID: 34171324 DOI: 10.1016/j.neubiorev.2021.06.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 04/30/2021] [Accepted: 06/19/2021] [Indexed: 02/04/2023]
Abstract
Visual hallucinations (VH) are common in Parkinson's disease and dementia with Lewy bodies, two forms of Lewy body disease (LBD), but the neural substrates and mechanisms involved are still unclear. We conducted meta-analyses of voxel-based morphometry (VBM) and neuropsychological studies investigating the neuroanatomical and cognitive correlates of VH in LBD. For VBM (12 studies), we used Seed-based d Mapping with Permutation of Subject Images (SDM-PSI), including statistical parametric maps for 50% of the studies. For neuropsychology (35 studies), we used MetaNSUE to consider non-statistically significant unreported effects. VH were associated with smaller grey matter volume in occipital, frontal, occipitotemporal, and parietal areas (peak Hedges' g -0.34 to -0.49). In patients with Parkinson's disease without dementia, VH were associated with lower verbal immediate memory performance (Hedges' g -0.52). Both results survived correction for multiple comparisons. Abnormalities in these brain regions might reflect dysfunctions in brain networks sustaining visuoperceptive, attention, and executive abilities, with the latter also being at the basis of poor immediate memory performance.
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Affiliation(s)
- Stefania Pezzoli
- Department of Neuroscience, University of Sheffield, Sheffield, UK; Molecular Biophysics and Integrated Bioimaging, Lawrence Berkeley National Laboratory, Berkeley, CA, USA; Helen Wills Neuroscience Institute, University of California Berkeley, Berkeley, CA, USA
| | - Raquel Sánchez-Valle
- Alzheimer's Disease and Other Cognitive Disorders Unit, Neurology Service, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Aleix Solanes
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain; Mental Health Research Networking Center (CIBERSAM), Madrid, Spain
| | - Matthew J Kempton
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Department of Neuroimaging, Institute of Psychiatry, Psychology and Neurosciences, King's College London, UK
| | - Oliver Bandmann
- Department of Neuroscience, University of Sheffield, Sheffield, UK
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, South Korea
| | | | - Jennifer G Goldman
- Shirley Ryan Ability Lab Parkinson's Disease and Movement Disorders program, Chicago, IL, USA; Northwestern University Feinberg School of Medicine, Departments of Physical Medicine and Neurology, Chicago, IL, USA
| | - Doug Merkitch
- Shirley Ryan Ability Lab Parkinson's Disease and Movement Disorders program, Chicago, IL, USA
| | - Michael J Firbank
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - John-Paul Taylor
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Javier Pagonabarraga
- Movement Disorders Unit, Neurology Department, Sant Pau Hospital, Barcelona, Spain; Universitat Autònoma de Barcelona (U.A.B.), Barcelona, Spain; Institut d'Investigacions Biomèdiques - Sant Pau (IIB-Sant Pau), Barcelona, Spain; Biomedical Research Networking Center on Neurodegenerative Diseases (CIBERNED), Madrid, Spain
| | - Jaime Kulisevsky
- Movement Disorders Unit, Neurology Department, Sant Pau Hospital, Barcelona, Spain; Universitat Autònoma de Barcelona (U.A.B.), Barcelona, Spain; Institut d'Investigacions Biomèdiques - Sant Pau (IIB-Sant Pau), Barcelona, Spain; Biomedical Research Networking Center on Neurodegenerative Diseases (CIBERNED), Madrid, Spain
| | - Frederic Blanc
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK; Geriatrics Day Hospital and Neuropsychology Unit, Geriatrics Department and Neurology Service, Memory Resources and Research Centre (CMRR), University Hospital of Strasbourg, Strasbourg, France; Team IMIS/Neurocrypto, French National Center for Scientific Research (CNRS), ICube Laboratory and Fédération de Médecine Translationnelle de Strasbourg (FMTS), University of Strasbourg, Strasbourg, France
| | - Norma Verdolini
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain; Mental Health Research Networking Center (CIBERSAM), Madrid, Spain; Bipolar and Depressive Disorders Unit, Institute of Neuroscience, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Annalena Venneri
- Department of Neuroscience, University of Sheffield, Sheffield, UK; Department of Life Sciences, Brunel University London, London, UK
| | - Joaquim Radua
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain; Mental Health Research Networking Center (CIBERSAM), Madrid, Spain; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Department of Clinical Neuroscience, Centre for Psychiatric Research and Education, Karolinska Institutet, Stockholm, Sweden.
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In the spotlight-Frontal lobe functions as germane to psychiatric practice. Asian J Psychiatr 2020; 50:101936. [PMID: 32088584 DOI: 10.1016/j.ajp.2020.101936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 02/08/2020] [Indexed: 11/21/2022]
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An octogenarian with Parkinson's disease psychosis that has responded favourably to low-dose sulpiride with facilitated motoric agility. Asian J Psychiatr 2019; 43:55-56. [PMID: 31082624 DOI: 10.1016/j.ajp.2019.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/23/2019] [Accepted: 05/02/2019] [Indexed: 11/22/2022]
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Lenka A, Reddy YCJ, Pal PK. Isolated tactile hallucination in a patient with Parkinson's disease: Quetiapine conquers the snakes and stones. Asian J Psychiatr 2018; 35:34-35. [PMID: 29754101 DOI: 10.1016/j.ajp.2018.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 04/27/2018] [Accepted: 05/07/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Abhishek Lenka
- Department of Clinical Neurosciences, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India; Department of Neurology, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
| | - Y C Janardhana Reddy
- Department of Psychiatry, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
| | - Pramod Kumar Pal
- Department of Neurology, National Institute of Mental Health & Neurosciences (NIMHANS), Hosur Road, Bangalore, 560029, Karnataka, India.
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