Are intravitreal injections essential during the COVID-19 pandemic? Global preferred practice patterns and practical recommendations

Tertiary outpatient ophthalmology clinics are high-risk environments for COVID-19 transmission, especially retina clinics, where regular follow-up is needed for elderly patients with multiple comorbidities. Intravitreal injection therapy (IVT) for chronic macular diseases, is one of the most common procedures performed, associated with a significant burden of care because of the vigorous treatment regimen associated with multiple investigations. While minimizing the risk of COVID-19 infection transmission is a priority, this must be balanced against the continued provision of sight-saving ophthalmic care to patients at risk of permanent vision loss. This review aims to give evidence-based guidelines on managing IVT during the COVID-19 pandemic in common macular diseases such as age-related macular degeneration, diabetic macula edema and retinal vascular disease and to report on how the COVID-19 pandemic has affected IVT practices worldwide.

To illustrate some real-world examples, 18 participants in the International Retina Collaborative, from 15 countries and across four continents, were surveyed regarding pre- and during- COVID-19 pandemic IVT practices in tertiary ophthalmic centers. The majority of centers reported a reduction in the number of appointments to reduce the risk of the spread of COVID-19 with varying changes to their IVT regimen to treat various macula diseases. Due to the constantly evolving nature of the COVID-19 pandemic, and the uncertainty about the normal resumption of health services, we suggest that new solutions for eye healthcare provision, like telemedicine, may be adopted in the future when we consider new long-term adaptations required to cope with the COVID-19 pandemic.

Dentin Staining Caused by Nano-silver Fluoride: A Comparative Study

CLINICAL RELEVANCE

The new formulations of nano-silver fluoride caused less dentin staining than the already available commercial agents 35% silver fluoride and silver diamine fluoride at 30% and 38%.

SUMMARY

The objective of this study was to evaluate the dentin staining potential of nano-silver fluoride (NSF 600 and 1500 ppm) compared with the following commercially available cariostatic agents: Advantage Arrest (Elevate Oral Care, West Palm Beach, FL, USA), Riva Star (SDI, Victoria, Australia), and Cariestop (Biodinâmica, Paraná, Brazil). Seventy-five extracted human molars were sectioned at the cementoenamel junction, and the occlusal enamel was removed for exposure of coronary dentin. The samples were divided among the five agents tested (n=15). The dentin staining (ΔE/ΔL) was analyzed with a digital spectrophotometer (VITA Easyshade, VITA Zahnfabrik, Bad Säckingen, Germany) at three different time points (before application, after two weeks, and after four weeks). Photographic images were also performed. The Kruskal-Wallis and Mann-Whitney tests compared the mean ΔE and ΔL values between groups. The NSF 600 and 1500 ppm resulted in the smallest color change (ΔE=1.02 and 1.53) and dentin staining after four weeks (ΔL=-0.76 and -1.2). The new formulations differed significantly from the commercial cariostatic agents (p<0.001). NSF might be an alternative to silver diamine fluoride since it does not compromise esthetics.

Local and systemic adverse effects of imiquimod therapy for external anogenital warts in men: report of three cases

Imiquimod is a topical immune response modifier used to treat anogenital warts. Although considered a safe drug, mild to moderate local and systemic side-effects may occasionally occur. We report three cases of local and systemic adverse effects related to imiquimod, including one case that mimicked meningitis, which promptly resolved with drug cessation.

Prevalence of enamel defects related to pre-, peri- and postnatal factors in a Brazilian population

OBJECTIVES

The aim of this paper is to evaluate the prevalence of enamel defects in infants from a socially and economically poor population and the possible association of these defects with disturbances occurring in the pre-, peri- and postnatal periods of human development.

PARTICIPANTS

117 infants aged between 16 and 18 months old were included in four groups based on gestational age and whether part or full term pregnancy.

METHOD

The data were collected in two stages: hospital-based, where gestational and birth records were examined, and home-based, where dental examinations and nutrition were evaluated. The teeth were cleaned and dried with gauze and examined in the open air, avoding direct sunlight in the knee-to-knee position. The enamel defects were coded according to the modified Developmental Defects of Enamel Index. Besides this, body weight and height were considered as anthropometric measures for the evaluation of nutritional status by the National Center for Health Statistics standards.

MAIN OUTCOME MEASURES

The data were analyzed using the chi-square and Fisher Exact tests. Besides these tests, logistic regression models were used.

RESULTS

The prevalence of enamel defects was 49.6%, higher in the group of male infants (p<0.001). The most frequent type of defect and the most affected surface were, respectively, diffuse opacity (9.5%) and the buccal surface (83.3%), located in the gingival half (6.7%). The logistic regression model showed that educational level, gestational age and intrauterine growth retardation (IUGR), besides a lack of breastfeeding, increased the probability of enamel defects up to level of 5%.

CONCLUSIONS

The association between enamel defects and the etiologic factors shown in this study suggest the existence of social influences regarding oral health and teeth development.

Silver diamine fluoride: a caries "silver-fluoride bullet"

The antimicrobial use of silver compounds pivots on the 100-year-old application of silver nitrate, silver foil, and silver sutures for the prevention and treatment of ocular, surgical, and dental infections. Ag(+) kills pathogenic organisms at concentrations of <50 ppm, and current/potential anti-infective applications include: acute burn coverings, catheter linings, water purification systems, hospital gowns, and caries prevention. To distill the current best evidence relative to caries, this systematic review asked: Will silver diamine fluoride (SDF) more effectively prevent caries than fluoride varnish? A five-database search, reference review, and hand search identified 99 human clinical trials in three languages published between 1966 and 2006. Dual review for controlled clinical trials with the patient as the unit of observation, and excluding cross-sectional, animal, in vitro studies, and opinions, identified 2 studies meeting the inclusion criteria. The trials indicated that SDF's lowest prevented fractions for caries arrest and caries prevention were 96.1% and 70.3%, respectively. In contrast, fluoride varnish's highest prevented fractions for caries arrest and caries prevention were 21.3% and 55.7%, respectively. Similarly, SDF's highest numbers needed to treat for caries arrest and caries prevention were 0.8 (95% CI=0.5-1.0) and 0.9 (95% CI=0.4-1.1), respectively. For fluoride varnish, the lowest numbers needed to treat for caries arrest and prevention were 3.7 (95% CI=3.4-3.9) and 1.1 (95% CI=0.7-1.4), respectively. Adverse events were monitored, with no significant differences between control and experimental groups. These promising results suggest that SDF is more effective than fluoride varnish, and may be a valuable caries-preventive intervention. As well, the availability of a safe, effective, efficient, and equitable caries-preventive agent appears to meet the criteria of both the WHO Millennium Goals and the US Institute of Medicine's criteria for 21st century medical care.

Enamel defects and its relation to life course events in primary dentition of Brazilian children: a longitudinal study

OBJECTIVE

To evaluate the cumulative incidence of enamel defects (ED) and its correlation with life course events such as malnutrition and pre- and postnatal infections, in a cohort of children of low socioeconomic status.

METHODS

The children were registered at birth and examined from 12 to 36 months of age. At the baseline, 246 were examined and in the follow-up, 228. The teeth were examined under natural light and dried with gauze. ED was determined by the DDE index.

RESULTS

Results show that gender was not significant. The cumulative incidence of ED at the last recall examination was 78.9%. The most prevalent type of defect was diffuse opacity, present on the gingival half of the buccal surface (p < 0.001). For logistic regression analysis maternal infections, intrauterine growth retardation (IUGR), malnutrition and postnatal infections were selected as predictor variables for the occurrence of enamel defects.

CONCLUSIONS

The results indicate that life course events such as undernutrition and childhood infections during teeth development may be associated with enamel defects in socioeconomically underprivileged communities and may compromise the oral health-related quality of life.

The association of CAG repeat length with clinical progression in Huntington disease

OBJECTIVE

To determine whether the rate of clinical progression in Huntington disease (HD) is influenced by the size of the CAG expansion.

METHODS

The dataset consisted of 3,402 examinations of 512 subjects seen through the Baltimore Huntington's Disease Center. Subjects were seen for a mean of 6.64 visits, with mean follow-up of 6.74 years. Subjects were administered the Quantified Neurological Examination, with its subsets the Motor Impairment and Chorea Scores, the Mini-Mental State Examination, and the HD Activities of Daily Living (ADL) Scale.

RESULTS

In an analysis based on the Random Effects Model, CAG length was significantly associated with the rate of progression of all measures except chorea and ADL. There was a significant interaction term between CAG length and disease duration for all measures except chorea. Further graphical exploration of the data supported these linear models and suggested that subjects at the low end of the expanded CAG repeat range may experience a more benign late course.

CONCLUSIONS

CAG repeat length has a small effect on rate of progression that may be clinically important over time. Individuals with the shortest expansions appear to have the best prognosis. These effects of the CAG length may be relevant in the analysis of clinical trials.

An open-label study of escitalopram (Lexapro) for the treatment of 'Depression of Alzheimer's disease' (dAD)

BACKGROUND

Depression is a frequent neuropsychiatric complication of Alzheimer's Disease.

METHODS

This study investigated the safety and effectiveness of escitalopram (LEXAPRO) for depression in AD (dAD) as defined by the NIMH consensus criteria in an 8-week, open-label treatment study.

CONCLUSION

Escitalopram was efficacious and safe for the treatment of dAD in this study. Larger, controlled studies are warranted to further assess the efficacy for mood and behavioral disturbances in this medically fragile population.

The Influence of Enamel Defects on the Development of Early Childhood Caries in a Population with Low Socioeconomic Status: A Longitudinal Study

The purpose of this study was to evaluate the influence of enamel defects in the development of dental caries and their association with feeding practices and oral health behaviors in a cohort study of low-socioeconomic children from birth to 36 months of age in northeastern Brazil. Subjects were registered at birth and examined from 12 to 36 months of age. At baseline, 246 children were examined and at follow-up 228. The teeth were clinically examined and dried with gauze under natural light. Enamel defects were determined using the Developmental Defects of Enamel (DDE) index. Dental caries was determined using WHO criteria. Data were analyzed using descriptive and analytical techniques. At 36 months 78.9% infants presented at least one tooth with enamel defects and 25% of the children had at least one decayed tooth. A total of 16.9% teeth with enamel defects had become decayed (p = 0.0001). Opacity with enamel hypoplasia was the defect most frequently associated with dental caries (p = 0.001). Only 0.9% of the teeth without enamel defects developed caries. Multivariate analyses revealed that enamel defects, night breast-feeding and poor oral hygiene habits were predictors of dental caries at 18 and 24 months (p < 0.05). Considering the risk factors evaluated at 30 months of age, the presence of enamel defects was the single predictor of caries development at 36 months (p = 0.0001). Enamel defects are strongly associated with early childhood caries and, therefore, this correlation must be considered when focussing on low-socioeconomic communities.

Differential impairment of spatial location memory in Huntington's disease

OBJECTIVE

To determine whether a differential impairment of spatial memory exists in Huntington's disease (HD).

METHODS

Patients with HD and age matched neurologically normal subjects, as well as patients with Alzheimer's disease (AD) and Parkinson's disease (PD), learned the locations of nine items on a 3 x 3 grid over as many as 10 trials. Delayed recall of the items and their spatial locations was tested.

RESULTS

Patient with HD performed worse than normal subjects on all measures, and intermediate between AD and PD patients. However, they were the only subject group in whom delayed recall of spatial locations was poorer than delayed recall of object identity. This effect was independent of the severity of dementia.

CONCLUSIONS

HD patients have a differential impairment in memory for object-location information. This finding may relate to the involvement of the caudate nucleus, the primary site of pathology in HD, in corticostriatal circuits linking it with parietal association cortex. It is also consistent with views of the dorsal striatum as responsible for the acquisition over trials of specific place responses.

Ethyl-EPA in Huntington disease: A double-blind, randomized, placebo-controlled trial

BACKGROUND

Preliminary evidence suggests beneficial effects of pure ethyl-eicosapentaenoate (ethyl-EPA) in Huntington disease (HD).

METHODS

A total of 135 patients with HD were randomized to enter a multicenter, double-blind, placebo-controlled trial on the efficacy of 2 g/d ethyl-EPA vs placebo. The Unified Huntington's Disease Rating Scale (UHDRS) was used for assessment. The primary end point was outcome at 12 months on the Total Motor Score 4 subscale (TMS-4). Analysis of covariance (ANCOVA) and a chi2 test on response, defined as absence of increase in the TMS-4, were performed.

RESULTS

A total of 121 patients completed 12 months, and 83 did so without protocol violations (PP cohort). Intent-to-treat (ITT) analysis revealed no significant difference between ethyl-EPA and placebo for TMS-4. In the PP cohort, ethyl-EPA proved better than placebo on the chi2 test on TMS-4 (p < 0.05), but missed significance on ANCOVA (p = 0.06). Secondary end points (ITT cohort) showed no benefit of ethyl-EPA but a significantly worse outcome in the behavioral severity and frequency compared with placebo. Exploring moderators of the efficacy of ethyl-EPA on TMS-4 showed a significant interaction between treatment and a factor defining patients with high vs low CAG repeats. Reported adverse events were distributed equally between treatment arms.

CONCLUSIONS

Ethyl-eicosapentaenoate (ethyl-EPA) (purity > 95%) had no benefit in the intent-to-treat cohort of patients with Huntington disease, but exploratory analysis revealed that a significantly higher number of patients in the per protocol cohort, treated with ethyl-EPA, showed stable or improved motor function. Further studies of the potential efficacy of ethyl-EPA are warranted.

Onset and rate of striatal atrophy in preclinical Huntington disease

BACKGROUND

Huntington disease (HD) is characterized by striatal atrophy that begins long before the onset of motor symptoms.

OBJECTIVE

To determine when striatal atrophy begins, the extent and rate of atrophy before diagnosis of motor symptoms, and whether striatal atrophy can predict when symptom onset will occur.

METHODS

Caudate and putamen volumes were measured on MRI scans of 19 preclinical subjects with the HD gene expansion who were very far (9 to 20 years) from estimated onset, and on serial scans from 17 preclinical subjects, six of whom were diagnosed with HD within 5 years after the initial scan.

RESULTS

Striatal volumes were significantly smaller for the subjects who were very far from estimated onset than for age-matched control subjects. Statistical models fit to the longitudinal data suggest that rate of caudate atrophy becomes significant when subjects are approximately 11 years from estimated onset and rate of putamen atrophy becomes significant approximately 9 years prior to onset. In the six incident cases, caudate and putamen were approximately one-third to one-half of normal volume at diagnosis, and caudate volume alone was able to predict with 100% accuracy those subjects who would be diagnosed within 2 years of imaging.

CONCLUSIONS

Striatal atrophy begins many years prior to diagnosable HD, and assessment of atrophy on MRI may be very useful in both predicting HD onset and in tracking progression in future therapeutic trials in preclinical subjects.

Breast-feeding and early childhood caries: an assessment among Brazilian infants

OBJECTIVES

The purpose of the present study was to evaluate early childhood caries among 12-36-month-old children from families living in poor socio-economic conditions in the city of Recife, Brazil, its association with the type and duration of feeding (e.g. natural, sugared, bottle and glass), as well as the relationship between a supplementary diet and the occurrence of this type of caries.

METHODS

The present study consisted of a visual clinical examination of teeth that had been previously cleaned with gauze. This was carried out under natural light in a waiting room. Four calibrated examiners performed the examination and the kappa test value was 8.0. The parents or guardians were interviewed for the following information: name, address, age, type of feeding, number of sugary meals, sugar intake and habitual diet. Some 468 children were included in this study. Their ages ranged from 12 to 36 months. The sample was comprised of 222 (47.4%) males and 246 females (52.6%).

RESULTS

Of the 468 children included in this study, 133 (28.4%) had caries. Only 59 (12.6%) of the children examined had been breast-fed, 20 (33.9%) of whom presented with caries. Three hundred and twenty-seven (69.9%) subjects had been bottle-fed with sugared milk, 86 (26%) of whom had caries. Two hundred and eight children had five or more sugary meals per day, 70 (33.6%) of whom had caries. No statistically significant relationship was seen between breast-feeding and the prevalence of tooth decay.

CONCLUSIONS

The results of the present study show that the prevalence of early childhood caries in 12-36-month-old children from poor backgrounds in Recife is in accordance with the rate found in other Brazilian cities and is extremely high compared with that of the world population as a whole. Early childhood caries was not clearly related to the type of feeding in this sample. The prevalence of early childhood caries increased with age, and the number of sugary snacks between meals and a cariogenic diet were strongly related to early childhood caries. The lack of fluoridated water and high rates of early childhood caries in lead the authors to suggest that fluoride dentifrice should be introduced at 12 months of age as a fluoride supplement and an important aid in the prevention of childhood caries. Additional studies in different cultures and societies need to be undertaken before a definitive conclusion can be drawn.

Caudate volume as an outcome measure in clinical trials for Huntington’s disease: a pilot study

Previous research has demonstrated that longitudinal change in caudate volume could be observed over a period of 3 years in subjects with Huntington's disease (HD). The current pilot study was designed to determine whether measurement of caudate change on magnetic resonance imaging (MRI) is a feasible and valid outcome measure in an actual clinical trial situation. We measured caudate volumes on pre- and post-treatment MRI scans from 19 patients at two sites who were participating in CARE-HD (Co-enzyme Q10 and Remacemide: Evaluation in Huntington's Disease), a 30-month clinical trial of remacemide and co-enzyme Q(10) in symptomatic patients with HD. Results from this pilot study indicated that decrease in caudate volume was significant over time. Power analysis indicated that relatively small numbers of subjects would be needed in clinical trials using caudate volume as an outcome measure. Advantages and disadvantages of using MRI caudate volume as an outcome measure are presented. We recommend the adoption of quantitative neuroimaging of caudate volume as an outcome measure in future clinical trials for treatments of HD.

Formocresol mutagenicity following primary tooth pulp therapy: an in vivo study

OBJECTIVES

To investigate whether formocresol, in Buckley's original formulation, is mutagenic in vivo to lymphocyte cultures obtained from the peripheral blood of children aged from 5 to 10 years old. These children were recruited from those attending the dental clinics of Recife City Council and the University of Pernambuco School of Dentistry, Brazil.

METHODS

The sample comprised 20 children who had primary teeth with cariously exposed vital pulps. Two venous blood samples were collected (6-8 ml) from each child, the first prior to vital pulpotomy (control group) and the second 24 h after pulpotomy (treated group). This research is a case-control study. The peripheral lymphocytes were grown in a complete culture medium consisting of 78% RPMI 1640 medium (a), supplemented with streptomycin (0.01 mg/ml), penicillin (0.005 ml(-1)), 20% fetal bovine serum (b) and 2% phytohemagglutinin (c). The lymphocytes were assessed for chromosomal aberrations via a previously published method which was modified. The cytogenetic analysis was performed in a blind test, where the slides were codified by an annotator and the scorers did not know which group they were analyzing. For each sample, this envolved the analysis of 200 metaphases. The level of significance adopted in the statistical test was 5.0% (p<0.05).

RESULTS

There was no statistically significant difference in clinical doses between the control and treated groups, using Wilcoxon's Signed Ranks test, for the chromosomal aberrations (P=0.251) and for the total chromosomal breaks (P=0.149). Although there were no statistically significant differences between the control and treated groups, Buckley's formocresol was mutagenic for one patient, raising doubt about the desirability of its use for pulpotomies in children.

CONCLUSIONS

The results revealed that, from a statistical standpoint, formocresol is not mutagenic. However, further investigations are required, preferably with a larger sample, in patients needing more than one pulpotomy in order to observe whether an increase in the quantity of the drug would increase the quantity of chromosome aberrations and also to verify individual susceptibility to chromosome alterations with the use of formocresol.

Interaction of normal and expanded CAG repeat sizes influences age at onset of Huntington disease

Huntington disease (HD) is a neurodegenerative disorder caused by the abnormal expansion of CAG repeats in the HD gene on chromosome 4p16.3. Past studies have shown that the size of expanded CAG repeat is inversely associated with age at onset (AO) of HD. It is not known whether the normal Huntington allele size influences the relation between the expanded repeat and AO of HD. Data collected from two independent cohorts were used to test the hypothesis that the unexpanded CAG repeat interacts with the expanded CAG repeat to influence AO of HD. In the New England Huntington Disease Center Without Walls (NEHD) cohort of 221 HD affected persons and in the HD-MAPS cohort of 533 HD affected persons, we found evidence supporting an interaction between the expanded and unexpanded CAG repeat sizes which influences AO of HD (P = 0.08 and 0.07, respectively). The association was statistically significant when both cohorts were combined (P = 0.012). The estimated heritability of the AO residual was 0.56 after adjustment for normal and expanded repeats and their interaction. An analysis of tertiles of repeats sizes revealed that the effect of the normal allele is seen among persons with large HD repeat sizes (47-83). These findings suggest that an increase in the size of the normal repeat may mitigate the expression of the disease among HD affected persons with large expanded CAG repeats.

A disorder similar to Huntington's disease is associated with a novel CAG repeat expansion

Huntington's disease (HD) is an autosomal dominant disorder characterized by abnormalities of movement, cognition, and emotion and selective atrophy of the striatum and cerebral cortex. While the etiology of HD is known to be a CAG trinucleotide repeat expansion, the pathways by which this mutation causes HD pathology remain unclear. We now report a large pedigree with an autosomal dominant disorder that is clinically similar to HD and that arises from a different CAG expansion mutation. The disorder is characterized by onset in the fourth decade, involuntary movements and abnormalities of voluntary movement, psychiatric symptoms, weight loss, dementia, and a relentless course with death about 20 years after disease onset. Brain magnetic resonance imaging scans and an autopsy revealed marked striatal atrophy and moderate cortical atrophy, with striatal neurodegeneration in a dorsal to ventral gradient and occasional intranuclear inclusions. All tested affected individuals, and no tested unaffecteds, have a CAG trinucleotide repeat expansion of 50 to 60 triplets, as determined by the repeat expansion detection assay. Tests for the HD expansion, for all other known CAG expansion mutations, and for linkage to chromosomes 20p and 4p were negative, indicating that this mutation is novel. Cloning the causative CAG expansion mutation for this new disease, which we have termed Huntington's disease-like 2, may yield valuable insight into the pathogenesis of HD and related disorders.

A repeat expansion in the gene encoding junctophilin-3 is associated with Huntington disease-like 2

We recently described a disorder termed Huntington disease-like 2 (HDL2) that completely segregates with an unidentified CAG/CTG expansion in a large pedigree (W). We now report the cloning of this expansion and its localization to a variably spliced exon of JPH3 (encoding junctophilin-3), a gene involved in the formation of junctional membrane structures.

A disorder similar to Huntington's disease is associated with a novel CAG repeat expansion

Huntington's disease (HD) is an autosomal dominant disorder characterized by abnormalities of movement, cognition, and emotion and selective atrophy of the striatum and cerebral cortex. While the etiology of HD is known to be a CAG trinucleotide repeat expansion, the pathways by which this mutation causes HD pathology remain unclear. We now report a large pedigree with an autosomal dominant disorder that is clinically similar to HD and that arises from a different CAG expansion mutation. The disorder is characterized by onset in the fourth decade, involuntary movements and abnormalities of voluntary movement, psychiatric symptoms, weight loss, dementia, and a relentless course with death about 20 years after disease onset. Brain magnetic resonance imaging scans and an autopsy revealed marked striatal atrophy and moderate cortical atrophy, with striatal neurodegeneration in a dorsal to ventral gradient and occasional intranuclear inclusions. All tested affected individuals, and no tested unaffecteds, have a CAG trinucleotide repeat expansion of 50 to 60 triplets, as determined by the repeat expansion detection assay. Tests for the HD expansion, for all other known CAG expansion mutations, and for linkage to chromosomes 20p and 4p were negative, indicating that this mutation is novel. Cloning the causative CAG expansion mutation for this new disease, which we have termed Huntington's disease-like 2, may yield valuable insight into the pathogenesis of HD and related disorders.

Familial influence on age of onset among siblings with Huntington disease

In order to provide data relevant to a search for modifying genes for age of onset in Huntington disease, we examined the relationship between CAG number and age of onset in a total of 370 individuals from 165 siblingships, in two cohorts of siblings with Huntington disease: an American group of 144 individuals from 64 siblingships, and a Canadian population of 255 individuals from 113 siblingships. Using a logarithmic model to regress the age of onset on the number of CAG triplets, we found that CAG number alone accounted for 65%-71% of the variance in age of onset. The siblingship an individual belonged to accounted for 11%-19% of additional variance. This adds to the previous evidence that there are familial modifiers of the age of onset, independent of the CAG number. Such modifiers may consist of additional genes, which could be the target of a linkage study. A linkage study is feasible with the cooperation of a number of major centers and may be made more efficient by concentrating on sibling pairs that are highly discordant for age of onset.

The Gln-Ala repeat transcriptional activator CA150 interacts with huntingtin: Neuropathologic and genetic evidence for a role in Huntington's disease pathogenesis

Huntington's disease (HD) is a neurodegenerative disease caused by polyglutamine expansion in the protein huntingtin (htt). Pathogenesis in HD appears to involve the formation of ubiquitinated neuronal intranuclear inclusions containing N-terminal mutated htt, abnormal protein interactions, and the aggregate sequestration of a variety of proteins (noticeably, transcription factors). To identify novel htt-interacting proteins in a simple model system, we used a yeast two-hybrid screen with a Caenorhabditis elegans activation domain library. We found a predicted WW domain protein (ZK1127.9) that interacts with N-terminal fragments of htt in two-hybrid tests. A human homologue of ZK1127.9 is CA150, a transcriptional coactivator with a N-terminal insertion that contains an imperfect (Gln-Ala)(38) tract encoded by a polymorphic repeat DNA. CA150 interacted in vitro with full-length htt from lymphoblastoid cells. The expression of CA150, measured immunohistochemically, was markedly increased in human HD brain tissue compared with normal age-matched human brain tissue, and CA150 showed aggregate formation with partial colocalization to ubiquitin-positive aggregates. In 432 HD patients, the CA150 repeat length explains a small, but statistically significant, amount of the variability in the onset age. Our data suggest that abnormal expression of CA150, mediated by interaction with polyglutamine-expanded htt, may alter transcription and have a role in HD pathogenesis.

Vascular dementia and Alzheimer's disease: is there a difference? A comparison of symptoms by disease duration

This study examined differences between vascular dementia (VaD) by the NINDS/AIRENS criteria and Alzheimer's disease (AD) on clinical grounds. A consecutive series of 517 patients with probable and possible VaD or AD were evaluated for cognitive, functional, and behavioral symptoms and separated into three subgroups by duration of dementia. These AD and VaD subgroups were then compared on a series of standardized clinical measures. The only consistent trends were for VaD patients to be more depressed, more functionally impaired, and less cognitively impaired within each disease duration subgroup. The authors conclude that there are few differences between clinically diagnosed VaD and AD. Subclassification of VaD into subgroups will improve the clinical utility of this nosologic entity.

Rate of caudate atrophy in presymptomatic and symptomatic stages of Huntington's disease

Previous research by our group demonstrated a longitudinal change in caudate volume for symptomatic subjects with Huntington's disease (HD), and suggested that volume of the caudate may be a useful outcome measure for therapeutic studies in symptomatic patients. The current study was designed to determine whether longitudinal change in caudate atrophy could be documented in presymptomatic carriers of the HD gene mutation, and to compare rate of change in these subjects with rate of change in mildly and moderately affected symptomatic patients. We measured caudate volumes on serial magnetic resonance image scans from 30 patients at three stages of HD: 10 presymptomatic; 10 with mild symptoms, as indicated by scores on the Quantified Neurological Exam (QNE) < or =35; and 10 with moderate symptoms (QNE >45). The mean interscan interval was 36 months. When analyzed separately, both symptomatic groups and the presymptomatic group demonstrated a significant change in caudate volume over time. Amount of change over time did not differ significantly among the three groups. We conclude that change in caudate volume may be a useful outcome measure for assessing treatment effectiveness in both presymptomatic and symptomatic subjects.

Criminal behavior and emotional disorder: comparing youth served by the mental health and juvenile justice systems

This study explored whether youth involved in joint service systems differed from single-agency users in terms of types of crimes committed and clinical functioning. Data from 4,924 youth involved in one county's public mental health and juvenile justice service systems were examined. Twenty percent of those youth receiving mental health services had recent arrest records, and 30% of youth arrested received mental health services. Of all youth arrested in the county, mental health service users had more arrests than non-mental health service users. A subsample of 94 mental health service users with arrests was matched on demographics with 94 mental health service users without arrests. Youth with arrests had a higher frequency of conduct disorder, higher Child Behavior Checklist Externalizing and Total Problem Scale scores, and more functional impairment on the Child and Adolescent Functional Assessment Scale as compared to youth without arrests. Implications for behavioral health service delivery were discussed.

Delusions and hallucinations in Alzheimer's disease: prevalence and clinical correlates

OBJECTIVES

The purpose of this study was to examine the frequency of delusions and hallucinations in patients with Alzheimer's disease (AD) and to investigate factors associated with each or the combination of the two.

DESIGN

This was a cross-sectional, case-control study.

SETTING

Neuropsychiatry and Memory Group, The Johns Hopkins University, USA.

PARTICIPANTS

Three hundred and forty-two community-residing patients with probable AD according to NINCDS/ADRDA criteria were included in the study.

MEASURES

Patients were assessed clinically for the presence of psychotic symptoms using the DSM-IV glossary definitions. The patients were also rated on standardized measures of cognitive impairment, depression, extrapyramidal symptoms, functional impairment and general health.

RESULTS

Seventy-five (22%) AD patients had delusions only, nine (3%) had hallucinations only and 30 (9%) had both delusions and hallucinations. Hallucinations were associated with less education, African-American race, more severe dementia, longer duration of illness, falls and use of anxiolytics. Delusions were associated with older age, depression, aggression, poor general health and use of antihypertensives. Patients with both delusions and hallucinations were similar to the patients with delusions only.

CONCLUSIONS

This study confirms the high prevalence of psychotic symptoms in AD patients encountered in clinical practice and suggests that individual psychotic symptoms have different associations.

Neuropsychiatry of Huntington's disease and other basal ganglia disorders

Degenerative diseases of the basal ganglia, such as Huntington's disease (HD), Parkinson's disease, and Wilson's disease, are characterized by motor, cognitive, and psychiatric manifestations. HD, in particular, can be considered a paradigmatic neuropsychiatric disorder that has all three components of the "Triadic Syndromes": dyskinesia, dementia, and depression. The authors examine the phenomenology, prevalence, and management of psychiatric disturbances occurring in diseases of the basal ganglia. They address psychiatric conditions such as depression, mania, psychosis, obsessive-compulsive disorders, aggression, irritability, apathy, sexual disorders, and delirium, discussing subtleties of diagnosis, and making reference to more unusual disorders of the basal ganglia, such as postencephalitic parkinsonism and Fahr's disease.

Trinucleotide repeat expansion and neuropsychiatric disease

Trinucleotide, or triplet, repeats consist of 3 nucleotides consecutively repeated (e.g., CCG CCG CCG CCG CCG) within a region of DNA, a not uncommon motif in the genome of humans and other species. In 1991, a new type of genetic mutation was discovered, known as a dynamic or expansion mutation, in which the number of triplets in a repeat increases and the length becomes unstable. During the past decade, nearly 20 diseases-including Huntington disease, 2 forms of the fragile X syndrome, and myotonic dystrophy-caused by trinucleotide repeat expansions have been identified. The unstable nature of the expanded repeat leads to remarkable patterns of inheritance in these diseases, distinctly at odds with traditional notions of mendelian genetics. We review the clinical and genetic features of these disorders, with a particular emphasis on their psychiatric manifestations. We also critically examine the hypothesis that expansion mutations may have an etiologic role in psychiatric diseases such as bipolar disorder, schizophrenia, and autism.

The General Medical Health Rating: a bedside global rating of medical comorbidity in patients with dementia

OBJECTIVE

Dementia is a serious public health problem. General medical comorbidity is common in dementia patients and critical to their care. However, little is known about medical comorbidity in these patients, and there are no straightforward bedside global rating scales for the seriousness of comorbid medical illness. This paper describes the development and measurement properties of the General Medical Health Rating (GHMR), a rapid global rating scale of medical comorbidity in dementia patients.

DESIGN

Interrater reliability, concurrent validity, and predictive validity of the GMHR are reported.

SETTING

An outpatient dementia clinic, assisted living, and nursing home.

PARTICIPANTS

A total of 819 consecutive dementia clinic outpatients and 180 consecutive admissions to Copper Ridge, a long-term care residence for people with dementia, were included in the study.

RESULTS

GMHR was found to be highly reliable (weighted kappa = .91). Across all stages and types of dementia, GMHR ratings were correlated with number of comorbid medical conditions, number of medications being taken for comorbid conditions, and with activity of daily living impairment, even after adjustment for severity of dementia. GMHR ratings were also a strong predictor of falls and of mortality in long-term care residents after adjustment for age and severity of dementia.

CONCLUSION

GMHR is a reliable, valid, global bedside measure of severity of general medical comorbidity for patients with dementia that can be used for clinical and research purposes.

Wandering behaviour in community-residing persons with dementia

OBJECTIVES

To examine wandering behaviour in elderly demented persons in the community setting with respect to dementia characteristics and other factors that might influence wandering behaviour; to generate a statistical model to assess the relative importance of these various factors in predicting wandering behaviour.

DESIGN

Cross-sectional, case-control investigation.

SETTING

University-affiliated outpatient neuropsychiatric assessment center.

PARTICIPANTS

Six hundred and thirty-eight consecutive community-residing new patients with dementia referred for evaluation.

MEASUREMENTS

Comprehensive neuropsychiatric evaluation, including rating with Mini-Mental State Examination; General Medical Health Rating; Comell Scale of Depression in Dementia and caregiver interview.

RESULTS

Wandering behaviour occurred in 17.4% of participants. It was significantly more prevalent in patients with Alzheimer Dementia (AD), patients with dementia of longer duration, and patients with more severe dementia. Wandering behaviour was associated with moderate to severe depression, delusions, hallucinations, and sleep disorder. Other significant associations of wandering behaviour included use of neuroleptic medication and male gender. After statistical adjustment for other variables, duration of dementia, severity of dementia and presence of sleep disorder retained significant statistical association with wandering behaviour.

CONCLUSIONS

Wandering behaviour among community-residing elderly dementia patients is associated with a number of factors, some of which may be subject to modification. It is possible that management of coexistent psychopathology, particularly of sleep disorder, and of the underlying disease process of AD would help to ameliorate this problematic behavioural disorder. Further investigation is warranted into the relationship between neuroleptic medication and wandering behaviour and into possible alternative measures to control agitation in elderly dementia patients.

Physical aggression in dementia patients and its relationship to depression

OBJECTIVE

The goal of this study was to determine the frequency of physically aggressive behavior in community-residing patients with dementia and its relationship to depression.

METHOD

A consecutive series of 541 patients with DSM-IV-defined dementia underwent comprehensive neuropsychiatric evaluation and were rated on the Cornell Scale for Depression in Dementia, the Mini-Mental State, the Psychogeriatric Dependency Rating Scale, and the General Medical Health Rating.

RESULTS

Physically aggressive behavior was exhibited by 79 patients in the 2 weeks before evaluation. Aggressive behavior was closely associated with moderate to severe depression, male gender, and greater impairment in activities of daily living, even after adjustment for delusions, hallucinations, sleep disturbance, and severity of cognitive impairment. After adjustment for depression, gender, and impairment in activities of daily living, there was no association between physically aggressive behavior and the presence of either delusions or hallucinations.

CONCLUSIONS

A substantial minority of patients with dementia exhibit physically aggressive behavior, and this aggression is strongly linked with the presence of depressive symptoms. It is possible that the identification and treatment of depression in dementia may be a means of preventing and managing physically aggressive behavior.

Unstable expansion of the CAG trinucleotide repeat in MAB21L1: report of a second pedigree and effect on protein expression

MAB21L1, originally termed CAGR1, is the human homologue of the C. elegans cell fate determining gene mab21. MAB21L1, mapped to 13q13, contains a highly polymorphic 5' untranslated CAG repeat that normally ranges from six to 31 triplets in length. A pedigree has been previously reported in which the repeat length is expanded to 45-50 triplets and is transmitted unstably between generations; the expansion did not correlate to a clinical phenotype but did exhibit somatic mosaicism. We now report a second pedigree with an expanded and unstably transmitted MAB21L1 CAG repeat of similar length. The expansion is not clearly associated with a clinical phenotype, though the complexity of the pedigree renders any conclusion concerning phenotype-genotype relationships speculative. The expansion did not result in decreased expression of MAB21L1 protein. The length, C-G rich composition, somatic mosaicism, and unstable transmission of the expanded CAG repeat in MAB21L1 resemble the premutations observed in other genes, such as FMR1 and MDPK, in which longer expanded repeats are associated with a clinical phenotype. This raises the possibility that longer expansions in the MAB21L1 repeat may also be associated with a clinical phenotype.

Patients with features similar to Huntington's disease, without CAG expansion in huntingtin

OBJECTIVE

To describe characteristics of gene-negative patients with clinical features of Huntington's disease (HD), exploring likely etiologies.

BACKGROUND

When a direct gene test became definitive for diagnosis of HD, we discovered a number of patients in our clinics in Baltimore, MD, and Cambridge, UK, believed or suspected to have HD who did not have the triplet repeat expansion.

METHODS

Patients were examined using standardized instruments, and given full neurologic and psychiatric evaluations. Those negative for HD were tested for dentatorubro-pallidoluysian atrophy, SCA-1, SCA-3, SCA-2, SCA-6, and other conditions as indicated.

RESULTS

Of 15 patients, 7 received specific diagnoses or appear to be sporadic cases, 4 have a possible but uncertain relation to HD, and 4 have unknown familial progressive movement disorders.

CONCLUSIONS

This last group of patients might be properly described as phenocopies of HD, some of which may be caused by unidentified triplet repeat expansions.

Prevalence of psychopathology among children and adolescents

OBJECTIVE

This study was done to update and expand information given in recent reviews, provide a more systematic critique of past research, identify current research trends and issues, and explore possible strategies for future research in child psychiatric epidemiology.

METHOD

The authors identified and reviewed 52 studies done over the past four decades that attempted to estimate the overall prevalence of child and adolescent psychiatric disorders.

RESULTS

About as many studies have been published since 1980 as were published before. Sample sizes ranged from 58 to 8,462; most were in the 500-1,000 range. Studies were carried out in over 20 countries, most frequently the United States and the United Kingdom. Subjects' ages ranged from 1 to 18 years. Rutter's criteria were the most frequently used for case definition; more recent studies were more likely to use DSM criteria. The most frequently used interview was the Rutter schedule. The most common time frame for calculating prevalence was the present, followed by 6 months and 1 year. Prevalence estimates of psychopathology ranged from approximately 1% to nearly 51% (mean = 15.8%). Median rates were 8% for preschoolers, 12% for preadolescents, 15% for adolescents, and 18% in studies including wider age ranges.

CONCLUSIONS

The evidence is less informative than expected because of several problems that continue to plague research on child and adolescent disorders. These involve sampling, case ascertainment, case definition, and data analyses and presentation. Progress in understanding the epidemiology of child disorders will largely depend on whether future research successfully meets these challenges.

Managing what you measure: creating outcome-driven systems of care for youth with serious emotional disturbances

This article presents the California System of Care Model for youth with severe emotional disturbances as an illustration of how ongoing assessment of the costs and outcomes of service delivery can be an integral part of a service delivery model. The core of this model, developed initially in Ventura County, California, is a five-step planning process that guides care system development and implementation. The implications of each stage of the planning process for evaluation and feedback at the child, family, and system levels are highlighted. A set of principles for selecting outcome measures deriving from the planning process are also presented that, in conjunction with the planning model, serve as guidelines for establishing outcome measures within care systems. The resulting specific plan for measuring system- and client-level outcomes deriving from this process, along with challenges to the implementation of the outcome management plan, is described.

Detecting alcohol use disorders in the severely mentally ill

The frequent co-occurrence of alcoholism with serious mental illnesses ("dual diagnosis") necessitates that clinicians are able to recognize its presence in people with disabling mental illnesses. This study demonstrates that professionals often miss the diagnosis, but that their ability to detect alcoholism can be greatly enhanced by the use of a simple screening tool. Members of an urban psychosocial rehabilitation program who received psychiatric treatment in an affiliated outpatient clinic were interviewed after their clinic therapists and rehabilitation counselors had been asked questions pertaining to their general health and substance use. The members were interviewed with two screening tests, the CAGE and the SMAST, and a clinical DSM-III-R diagnosis of alcohol use disorder was established. Both the SMAST and CAGE had good sensitivity and the addition of a screener enhanced the clinicians' ability to detect alcohol use disorders.

Frontal lobe volume in patients with Huntington's disease

Neuropathologic and neuroimaging studies have suggested that frontal lobes are affected in Huntington's disease (HD), and that atrophy in this region may be associated with some of the cognitive impairment and clinical decline observed in patients with HD. We measured gray and white matter volumes within the frontal lobes on MRI for 20 patients with HD (10 mildly affected and 10 moderately affected) and 20 age- and sex-matched control subjects. We also correlated frontal lobe measurements with measures of symptom severity and cognitive function. Patients who were mildly affected had frontal lobe volumes (both gray and white matter) essentially identical to those of control subjects, despite clearly abnormal basal ganglia. Patients who were moderately affected demonstrated significant reductions in total frontal lobe volume (17%) and frontal white matter volume (28%). Frontal lobe white matter volume reductions, but not total frontal lobe volume reductions, were disproportionately greater than overall brain volume reductions (17%). Frontal lobe volume correlated with symptom severity and general cognitive function, but these correlations did not remain significant after taking into account total brain volume. We conclude that cognitive impairment and symptom severity are associated with frontal lobe atrophy, but this association is not specific to the frontal lobes. Frontal lobe atrophy (like total brain atrophy) occurs in later stages of increasing HD symptom severity and this atrophy primarily involves white matter.

Psychiatric care for patients with HIV infection. The varying perspectives

This article reviews the literature on the classification and treatment of psychiatric morbidity associated with infection from the human immunodeficiency virus (HIV). The psychiatric disorders seen in HIV-infected patients are formulated by using one of the following four perspectives as treatment guides: 1) the syndromal or disease perspective, 2) the dispositional or personality perspective, 3) the behavioral or addictive perspective, and 4) the life story perspective.

Manic syndrome early and late in the course of HIV

In a chart review at a hospital's infectious disease AIDS clinic, manic syndromes affected 8% of patients who had AIDS. Of the 14 patients with manic episodes, those without a family or personal history of mood disorder presented later in the course of HIV infection and had a higher prevalence of comorbid dementia.

Why do people need self-esteem? Converging evidence that self-esteem serves an anxiety-buffering function

Three studies were conducted to assess the proposition that self-esteem serves an anxiety-buffering function. In Study 1, it was hypothesized that raising self-esteem would reduce anxiety in response to vivid images of death. In support of this hypothesis, Ss who received positive personality feedback reported less anxiety in response to a video about death than did neutral feedback Ss. In Studies 2 and 3, it was hypothesized that increasing self-esteem would reduce anxiety among individuals anticipating painful shock. Consistent with this hypothesis, both success and positive personality feedback reduced Ss' physiological arousal in response to subsequent threat of shock. Thus, converging evidence of an anxiety-buffering function of self-esteem was obtained.

Why do people need self-esteem? Converging evidence that self-esteem serves an anxiety-buffering function

Three studies were conducted to assess the proposition that self-esteem serves an anxiety-buffering function. In Study 1, it was hypothesized that raising self-esteem would reduce anxiety in response to vivid images of death. In support of this hypothesis, Ss who received positive personality feedback reported less anxiety in response to a video about death than did neutral feedback Ss. In Studies 2 and 3, it was hypothesized that increasing self-esteem would reduce anxiety among individuals anticipating painful shock. Consistent with this hypothesis, both success and positive personality feedback reduced Ss' physiological arousal in response to subsequent threat of shock. Thus, converging evidence of an anxiety-buffering function of self-esteem was obtained.