Constructing a hospital post-stroke depression management protocol by studying the management of post-stroke depression in a hospital setting

Introduction

A stroke is a potentially debilitating event which can render the victim unable to perform many tasks and functions, significantly decreasing their quality of life. This, in addition to emotional/mental changes post-stroke, can lead to a phenomenon known as “post stroke depression” (PSD), characterised by persistent low mood following a stroke.

Objectives

This study aims to amalgamate recommendations based on national guidelines and previous literature, in addition to an original inpatient study of stroke patients within a hospital, to construct a standardised protocol of the management of PSD in the hospital setting.

Methods

248 patients who had been treated for stroke within a hospital were analysed using hospital notes to assess for incidence of PSD, in-hospital management, and outpatient follow-up. In addition a literature search was conducted and national guidelines were consulted to develop a PSD management protocol.

Figure 1: Post stroke depression management protocol.

Results

While 8% (20/248) of stroke patients experienced low mood immediately post stroke, 45% (9/20) of these patients did not receive any therapy or drug treatment, 80% (16/20) did not receive any outpatient monitoring of their mood and 100% of patients received no outpatient monitoring of newly commenced antidepressants.

Conclusions

Using the results and literature search, a PSD management protocol, encompassing both appropriate in-hospital therapy and robust outpatient monitoring, was developed (Figure 1). We hope that through this, hospital care of PSD can be improved and optimised, in order for victims of PSD to receive the best possible, evidence-based care available to treat this potentially devastating condition.

Disclosure

No significant relationships.

CT KUB scans for renal colic: Optimisation of scan range to reduce patient radiation burden

INTRODUCTION

Non-contrast CT KUB scans performed to assess renal colic should be limited to scanning between the upper pole of the highest kidney and the pubic symphysis to minimise unnecessary irradiation. This audit aimed to assess the amount of overscanning in CT KUBs outside this range.

METHODS

CT KUB scans taken over a 10-day period were assessed. Unnecessary overscan above the highest kidney was measured as a percentage of the total scan range. A target of less than 10% overscanning was set. The vertebral position of the upper pole of the highest kidney was also measured and compared to the actual level of the scan.

RESULTS

88 patients were assessed. 89.8% (79/88) of scans didn't meet the target of less than 10% overscanning above the highest kidney, and were associated with a higher radiation dose to the patient. The average overscanning above the highest pole of the kidney was 16.4% of the whole scan. The average overscan below the pubic symphysis was 1.54%. We also found that 100% of scanned kidneys lied below the upper border of the T11 vertebra, in spite of scans starting as high as T7.

CONCLUSION

A large proportion of scans included unnecessary overscanning above the highest kidney. We have identified the upper border of the T11 vertebral body as a potential location from which to begin the upper margin of a CT KUB scan.

IMPLICATIONS FOR PRACTICE

By starting CT KUB scans at the upper border of the T11 vertebral body, we can allow the whole kidney to be imaged while minimising unnecessary overscanning above the kidney, thus lowering excess patient irradiation while still producing high quality scans.

Active lifestyles moderate clinical outcomes in autosomal dominant frontotemporal degeneration

INTRODUCTION

Leisure activities impact brain aging and may be prevention targets. We characterized how physical and cognitive activities relate to brain health for the first time in autosomal dominant frontotemporal lobar degeneration (FTLD).

METHODS

A total of 105 mutation carriers (C9orf72/MAPT/GRN) and 69 non-carriers reported current physical and cognitive activities at baseline, and completed longitudinal neurobehavioral assessments and brain magnetic resonance imaging (MRI) scans.

RESULTS

Greater physical and cognitive activities were each associated with an estimated >55% slower clinical decline per year among dominant gene carriers. There was also an interaction between leisure activities and frontotemporal atrophy on cognition in mutation carriers. High-activity carriers with frontotemporal atrophy (-1 standard deviation/year) demonstrated >two-fold better cognitive performances per year compared to their less active peers with comparable atrophy rates.

DISCUSSION

Active lifestyles were associated with less functional decline and moderated brain-to-behavior relationships longitudinally. More active carriers "outperformed" brain volume, commensurate with a cognitive reserve hypothesis. Lifestyle may confer clinical resilience, even in autosomal dominant FTLD.

Comparison of sporadic and familial behavioral variant frontotemporal dementia (FTD) in a North American cohort

INTRODUCTION

Behavioral variant frontotemporal dementia (bvFTD) may present sporadically or due to an autosomal dominant mutation. Characterization of both forms will improve understanding of the generalizability of assessments and treatments.

METHODS

A total of 135 sporadic (s-bvFTD; mean age 63.3 years; 34% female) and 99 familial (f-bvFTD; mean age 59.9; 48% female) bvFTD participants were identified. f-bvFTD cases included 43 with known or presumed chromosome 9 open reading frame 72 (C9orf72) gene expansions, 28 with known or presumed microtubule-associated protein tau (MAPT) mutations, 14 with known progranulin (GRN) mutations, and 14 with a strong family history of FTD but no identified mutation.

RESULTS

Participants with f-bvFTD were younger and had earlier age at onset. s-bvFTD had higher total Neuropsychiatric Inventory Questionnaire (NPI-Q) scores due to more frequent endorsement of depression and irritability.

DISCUSSION

f-bvFTD and s-bvFTD cases are clinically similar, suggesting the generalizability of novel biomarkers, therapies, and clinical tools developed in either form to the other.

Narrative Matters: A Monster Calls - a portrayal of dissociation in childhood bereavement

'A Monster Calls' is a children's fantasy novel written by Patrick Ness, based on an original idea by Siobhan David. Released to critical acclaim, the novel was lauded on its dealing of complex issues relating to bereavement and grief in a manner accessible to its younger readers. This article explores how 'A Monster Calls' presents a portrayal of a dissociative child in response to bereavement, and what impact this portrayal may have on the novel's younger readership.

Flowers for Algernon: The ethics of human experimentation on the intellectually disabled

Flowers for Algernon is a novel written in 1966 by Daniel Keyes. Since its publication, it has received significant critical acclaim, earning a Nebula science-fiction award, and was also adapted into a feature film. Set in the 1960s, the novel follows the story of Charlie Gordon, an intellectually disabled man who lives a simple but happy life working a cleaning job at a local bakery. Charlie's life, however, faces an abrupt change when he is offered the opportunity to participate in a novel surgical procedure to improve his intellect. Although he doesn't fully understand the risks of the operation, consent is provided on his behalf by his estranged sister and Charlie undergoes the experiment. The experiment is a success and Charlie develops intellectually at an alarming pace, soon surpassing the experimenters themselves. The rest of the book follows the, not all positive, changes that this intellect brings to Charlie's life. The novel is set in a time when American scientific experimentation could often occur without fully informed consent. This article explores the ethical side of such experiments like the one performed on Charlie, namely if it is morally right to perform a potentially dangerous experimental procedure on someone who doesn't fully understand the risks, even if it will potentially help them.

Improving CSF biomarker accuracy in predicting prevalent and incident Alzheimer disease

OBJECTIVE

To investigate factors, including cognitive and brain reserve, which may independently predict prevalent and incident dementia of the Alzheimer type (DAT) and to determine whether inclusion of identified factors increases the predictive accuracy of the CSF biomarkers Aβ(42), tau, ptau(181), tau/Aβ(42), and ptau(181)/Aβ(42).

METHODS

Logistic regression identified variables that predicted prevalent DAT when considered together with each CSF biomarker in a cross-sectional sample of 201 participants with normal cognition and 46 with DAT. The area under the receiver operating characteristic curve (AUC) from the resulting model was compared with the AUC generated using the biomarker alone. In a second sample with normal cognition at baseline and longitudinal data available (n = 213), Cox proportional hazards models identified variables that predicted incident DAT together with each biomarker, and the models' concordance probability estimate (CPE), which was compared to the CPE generated using the biomarker alone.

RESULTS

APOE genotype including an ε4 allele, male gender, and smaller normalized whole brain volumes (nWBV) were cross-sectionally associated with DAT when considered together with every biomarker. In the longitudinal sample (mean follow-up = 3.2 years), 14 participants (6.6%) developed DAT. Older age predicted a faster time to DAT in every model, and greater education predicted a slower time in 4 of 5 models. Inclusion of ancillary variables resulted in better cross-sectional prediction of DAT for all biomarkers (p < 0.0021), and better longitudinal prediction for 4 of 5 biomarkers (p < 0.0022).

CONCLUSIONS

The predictive accuracy of CSF biomarkers is improved by including age, education, and nWBV in analyses.

Alzheimer disease identification using amyloid imaging and reserve variables: proof of concept

OBJECTIVE

Several factors may influence the relationship between Alzheimer disease (AD) lesions and the expression of dementia, including those related to brain and cognitive reserve. Other factors may confound the association between AD pathology and dementia. We tested whether factors thought to influence the association of AD pathology and dementia help to accurately identify dementia of the Alzheimer type (DAT) when considered together with amyloid imaging.

METHODS

Participants with normal cognition (n = 180) and with DAT (n = 25), aged 50 years or older, took part in clinical, neurologic, and psychometric assessments. PET with the Pittsburgh compound B (PiB) tracer was used to measure brain amyloid, yielding a mean cortical binding potential (MCBP) reflecting PiB uptake. Logistic regression was used to generate receiver operating characteristic curves, and the areas under those curves (AUC), to compare the predictive accuracy of using MCBP alone vs MCBP together with other variables selected using a stepwise selection procedure to identify participants with DAT vs normal cognition.

RESULTS

The AUC resulting from MCBP alone was 0.84 (95% confidence interval [CI] = 0.73-0.94; cross-validated AUC = 0.80, 95% CI = 0.68-0.92). The AUC for the predictive equation generated by a stepwise model including education, normalized whole brain volume, physical health rating, gender, and use of medications that may interfere with cognition was 0.94 (95% CI = 0.90-0.98; cross-validated AUC = 0.91, 95% CI = 0.85-0.96), an improvement (p = 0.025) over that yielded using MCBP alone.

CONCLUSION

Results suggest that factors reported to influence associations between AD pathology and dementia can improve the predictive accuracy of amyloid imaging for the identification of symptomatic AD.

Pathological glial tau accumulations in neurodegenerative disease: review and case report

Abnormal deposits of tau protein accumulate in glia in many neurodegenerative diseases. This suggests that in some instances the disease process may target glial tau, with neuronal degeneration a secondary consequence of this process. In this report, we summarize the pattern of glial tau pathology in various neurodegenerative disorders and add original findings from a case of sporadic frontotemporal dementia that exhibits astrocytic tau pathology. The neurodegenerative diseases span the spectrum of relative neuronal and glial tau involvement, from disorders affecting only neuronal tau to those in which abnormal tau deposits are found only in glia. From this, we conclude that glial tau can be a primary target of the disease process, and that this can lead to neuronal degeneration.

Tau-66: evidence for a novel tau conformation in Alzheimer's disease

We have characterized a novel monoclonal antibody, Tau-66, raised against recombinant human tau. Immunohistochemistry using Tau-66 reveals a somatic-neuronal stain in the superior temporal gyrus (STG) that is more intense in Alzheimer's disease (AD) brain than in normal brain. In hippocampus, Tau-66 yields a pattern similar to STG, except that neurofibrillary lesions are preferentially stained if present. In mild AD cases, Tau-66 stains plaques lacking obvious dystrophic neurites (termed herein 'diffuse reticulated plaques') in STG and the hippocampus. Enzyme-linked immunosorbent assay (ELISA) analysis reveals that Tau-66 is specific for tau, as there is no cross-reactivity with MAP2, tubulin, Abeta(1-40), or Abeta(1-42), although Tau-66 fails to react with tau or any other polypeptide on western blots. The epitope of Tau-66, as assessed by ELISA testing of tau deletion mutants, appears discontinuous, requiring residues 155-244 and 305-314. Tau-66 reactivity exhibits buffer and temperature sensitivity in an ELISA format and is readily abolished by SDS treatment. Taken together these lines of evidence indicate that the Tau-66 epitope is conformation-dependent, perhaps involving a close interaction of the proline-rich and the third microtubule-binding regions. This is the first indication that tau can undergo this novel folding event and that this conformation of tau is involved in AD pathology.

Structural analysis of Pick's disease-derived and in vitro-assembled tau filaments

Pick's and Alzheimer's diseases are distinct neurodegenerative disorders both characterized in part by the presence of intracellular filamentous tau protein inclusions. The tight bundles of paired helical filaments (PHFs) of tau protein found in Alzheimer's disease (AD) differ from the tau filaments of Pick's disease in their morphology, distribution, and pathological structure as identified by silver impregnation. The filaments of Pick's disease are loosely arranged in pathognomonic spherical inclusions found in ballooned neurons, whereas the tau pathology of AD is classically described as a triad of neuropil threads, neurofibrillary tangles, and dystrophic neurites surrounding and invading plaques. In this study we used the high-resolution technique of scanning transmission electron microscopy to characterize and compare the filaments found in Pick's disease with those found in AD. In addition, we determined the mass/nm length and density of arachidonic acid-induced in vitro-assembled filaments. Three morphologically distinct populations of Pick's filaments were identified but each was indistinguishable from AD-PHFs in mass/nm length and density. Filaments assembled in vitro from single isoforms were similar in mass/nm length, but less dense than AD-PHFs and Pick's disease filaments. Finally, we provide clear structural evidence that a PHF, whether found in disease or assembled in vitro, is composed of two distinct intertwined filaments.

Inhibition of neuronal maturation in primary hippocampal neurons from τ deficient mice

Conflicting evidence supports a role for τ as an essential neuronal cytoskeletal protein or as a redundant protein whose function can be fulfilled by other microtubule-associated proteins. To investigate the function of τ in axonogenesis, we created τ deficient mice by disrupting the TAU gene. The engineered mice do not express the τ protein, appear physically normal and are able to reproduce. In contrast to a previously reported τ knockout mouse, embryonic hippocampal cultures from τ deficient mice show a significant delay in maturation as measured by axonal and neuritic extensions. The classic technique of selectively enhancing axonal growth by growth on laminin substrates failed to restore normal neuronal maturation of τ knockout neurons. By mating human TAU-gene transgenic and τ knockout mice, we reconstituted τ-deficient neurons with human τ proteins and restored a normal pattern of axonal growth and neuronal maturation. The ability of human τ proteins to rescue τ-deficient mouse neurons confirms that τ expression affects the rate of neurite extension.

C-terminal inhibition of tau assembly in vitro and in Alzheimer's disease

Alzheimer's disease (AD) is, in part, defined by the polymerization of tau into paired helical and straight filaments (PHF/SFs) which together comprise the fibrillar pathology in degenerating brain regions. Much of the tau in these filaments is modified by phosphorylation. Additionally, a subset also appears to be proteolytically truncated, resulting in the removal of its C terminus. Antibodies that recognize tau phosphorylated at S(396/404)or truncated at E(391) do not stain control brains but do stain brain sections very early in the disease process. We modeled these phosphorylation and truncation events by creating pseudo-phosphorylation and deletion mutants derived from a full-length recombinant human tau protein isoform (ht40) that contains N-terminal exons 2 and 3 and all four microtubule-binding repeats. In vitro assembly experiments demonstrate that both modifications greatly enhance the rates of tau filament formation and that truncation increases the mass of polymer formed, as well. Removal of as few as 12 or as many as 121 amino acids from the C terminus of tau greatly increases the rate and extent of tau polymerization. However, deletion of an additional 7 amino acids, (314)DLSKVTS(320), from the third microtubule-binding repeat results in the loss of tau's ability to form filaments in vitro. These results suggest that only part of the microtubule-binding domain (repeats 1, 2 and a small portion of 3) is crucial for tau polymerization. Moreover, the C terminus of tau clearly inhibits the assembly process; this inhibition can be partially reversed by site-specific phosphorylation and completely removed by truncation events at various sites from S(320) to the end of the molecule.

Casein kinase 1 delta is associated with pathological accumulation of tau in several neurodegenerative diseases

The distribution of casein kinase 1 delta (Cki delta) was studied by immunohistochemistry and correlated with other pathological hallmarks in Alzheimer's disease (AD), Down syndrome (DS), progressive supranuclear palsy (PSP), parkinsonism dementia complex of Guam (PDC), Pick's disease (PiD), pallido-ponto-nigral degeneration (PPND), Parkinson's disease (PD), dementia with Lewy bodies (DLB), amyotrophic lateral sclerosis (ALS), and elderly controls. Cki delta was found to be associated generally with granulovacuolar bodies and tau-containing neurofibrillary tangles in AD, DS, PSP, PDC, PPND, and controls, and Pick bodies and ballooned neurons in PiD. It was not associated with tau-containing inclusions in astroglia and oligodendroglia in PPND, PSP, and PDC. It was also not associated with tau-negative Lewy bodies in PD and DLB, Hirano bodies in PDC, Marinesco bodies in PD, AD, and controls and "skein"-like inclusions in anterior motor neurons in ALS. The colocalization of the kinase Cki delta and its apparent substrate tau suggests a function for Cki delta in the abnormal processing of tau.

A new molecular link between the fibrillar and granulovacuolar lesions of Alzheimer's disease

Alzheimer's Disease (AD) is a progressive neurodegenerative disorder involving select neurons of the hippocampus, neocortex, and other regions of the brain. Markers of end stage disease include fibrillar lesions, which accumulate hyperphosphorylated tau protein polymerized into filaments, and granulovacuolar lesions, which appear primarily within the hippocampus. The mechanism by which only select populations of neurons develop these lesions as well as the relationship between them is unknown. To address these questions, we have turned to AD tissue to search for enzymes specifically involved in tau hyperphosphorylation. Recently, we showed that the principal phosphotransferases associated with AD brain-derived tau filaments are members of the casein kinase-1 (CK1) family of protein kinases. Here we report the distribution of three CK1 isoforms (Ckialpha, Ckidelta, and Ckiepsilon) in AD and control brains using immunohistochemistry and Western analysis. In addition to colocalizing with elements of the fibrillar pathology, CK1 is found within the matrix of granulovacuolar degeneration bodies. Furthermore, levels of all CK1 isoforms are elevated in the CA1 region of AD hippocampus relative to controls, with one isoform, Ckidelta, being elevated >30-fold. We propose that overexpression of this protein kinase family plays a key role in the hyperphosphorylation of tau and in the formation of AD-related pathology.

Computer aids in drug design--highlights

An outline of some procedures used for computer aided drug design has been given. The emphasis is on lead generation, both primary and secondary, and on current lead optimization processes which rely on an appreciation of ligand-receptor interactions. The areas covered include techniques for structure based drug design and lead optimization, ligand-receptor interaction studies using molecular surfaces and docking, extraction of pharmacophore pattern to obtain new leads, expert system application etc.