Change of symptoms of schizophrenia across phases of menstrual cycle

The relation between schizophrenia and the menstrual cycle has always been found attractive by researchers. It is still a question of debate whether the clinical picture changes during the menstrual cycle. Our study aimed to see whether there is any change of symptoms during different phases of menstrual cycle (premenstrual, menstrual, and postmenstrual) in patients suffering from schizophrenia. Over a period of 15 months, 40 female inpatients of a tertiary care psychiatric hospital with the diagnosis of schizophrenia were assessed by applying PANSS. Rating was done up to two menstrual cycles. Total scores, positive and negative subscale scores, and general psychopathology scores of PANSS in premenstrual, menstrual, and postmenstrual phases of those patients were compared with one another by applying paired t test. Symptoms in women suffering from schizophrenia frequently vary with the different phases of menstrual cycle. The positive symptoms improved significantly only during progesterone phase. Negative symptoms and general psychopathology subscale showed improvement on estrogen phases of menstrual cycle. So optimal treatment needs to be adjusted to the individual women suffering from schizophrenia.

Ninety-Day Morbidity and Mortality in Risk-Screened and Optimized Patients Undergoing Two-Team Fast-Track Simultaneous Bilateral TKA Compared With Unilateral TKA-A Prospective Study

BACKGROUND

Simultaneous bilateral total knee arthroplasty (SBTKA) offers significant socioeconomic benefits. However, retrospective studies and public health data show increased mortality and morbidity rates in patients undergoing SBTKA compared with those undergoing unilateral TKA (UTKA), and there have been recommendations against the use of SBTKA. High-volume centers, which feature careful patient selection and fast-tracked surgery, continue to perform SBTKA and have published their results in favor of the procedure. However, the quality of evidence remains poor.

METHODS

We prospectively examined 90-day morbidity and mortality of SBTKA compared with UTKA in risk-screened and optimized patients in our high-volume joint replacement facility. A total of 1200 consecutive patients were recruited in each arm.

RESULTS

Ninety-day mortality was higher in SBTKA patients than in UTKA patients (0.58% vs 0.42%, respectively; P = .5646). Overall procedure-related complications were significantly higher in the SBTKA group (7.25% vs 4.42%, respectively; P = .0034). The relative risk of cardiovascular complications in SBTKA patients was 6.5 times higher than that in UTKA patients (1.08% vs 0.17%, respectively; P = .0136). Neurological complications were 9.5 times more common in the SBTKA group (1.58% vs 0.17%, respectively; P = .0024). All other complications were comparable in the 2 groups.

CONCLUSION

Risk screening and preoperative optimization reduce mortality and overall complication rates in SBTKA patients; however, overall procedure-related complications, specifically cardiovascular and neurological, remain significantly high in SBTKA patients, for which a guarded approach is recommended.

Co-morbidity of Obsessive-compulsive Disorder and Other Anxiety Disorders with Child and Adolescent Mood Disorders

OBJECTIVE

To assess the co-morbidity of obsessive-compulsive disorder (OCD) and other anxiety disorders in child and adolescent mood disorders.

METHODS

A total of 100 patients aged < 18 years with mood disorders according to the DSM-IV-TR were screened for OCD and other anxiety disorders using Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime version.

RESULTS

The prevalence of co-morbid anxiety disorders was 22%; OCD was present in 4%, and subthreshold obsessive-compulsive symptoms were present in 2%. Among others, 8% had panic disorder, 7% had generalised anxiety disorder, 3% had separation anxiety disorder, and 1% had social phobia; multiple anxiety disorders were present in 3% of patients.

CONCLUSION

Co-morbid anxiety disorder was found in one-fifth of children and adolescents with mood disorder.

Extremity and Orthopaedic Injuries

The extremities remain the most common sites of wounding in combat, and are often a combination of injures to soft tissues, bones, vessels and nerves. While these injuries are managed only after life threatening injuries are tackled first, precise evaluation and prompt management strategies to attain optimal outcome remain the goals of treatment. With advancements in tourniquet science, broader spectrum antibiotics, use of negative pressure wound therapy, easier options for fracture stabilization and continuously evolving reconstructive procedures have all increased the tools available to the surgeon to salvage severely damaged limbs.

Schizencephaly associated with bipolar II disorder

A 55-year-old man with congenital hemiparesis of the right side, three episodes of generalised tonic-clonic seizure at 16 years of age, and two episodes of severe depression and two episodes of hypomania in the past, presented with severe depression with psychotic symptoms. Computed tomography of the brain showed a grey matter-lined cerebrospinal fluid-filled cleft in the left cerebral hemisphere, involving the temporoparietal region. He was diagnosed to have bipolar II disorder, and was currently severely depressed with psychotic symptoms and schizencephaly. He improved with sodium valproate 1,000 mg/day, quetiapine 450 mg/day and escitalopram 20 mg/day after three weeks without any emergent side effects, and was maintaining well at three months follow-up. Although uncommon, schizencephaly may be considered as one of the differentials in cases of bipolar disorder along with congenital hemiparesis, mental retardation and/or seizures; and neuroimaging should be done to confirm the diagnosis.

Event-related potential: An overview

Electroencephalography (EEG) provides an excellent medium to understand neurobiological dysregulation, with the potential to evaluate neurotransmission. Time-locked EEG activity or event-related potential (ERP) helps capture neural activity related to both sensory and cognitive processes. In this article, we attempt to present an overview of the different waveforms of ERP and the major findings in various psychiatric conditions.

Right Atrial Trans-Septal Approach for Left Atrial Myxomas—Nine-Year Experience

OBJECTIVE

In this single-center study we reviewed our experience with left atrial myxomas occurring over the past 9 years.

METHODS

Sixty-three patients underwent excision of cardiac myxomas between 1995 and 2004. Of these, 56 patients (32 females and 24 males) had left atrial (LA) myxoma. The mean age was 37.80+12.97 years (range 3.5-67 years). Echocardiography was the only diagnostic evaluation done. The preferred approach for resection was right atrial trans-septal. Annual echocardiographic evaluation was undertaken following surgery. Follow-up is current and available in all the survivors (range 4 months-9 years).

RESULTS

Clinically 75% of the LA myxomas simulated mitral stenosis. The symptoms were present for 2-6 months before operation. Most (86%) LA myxomas were attached to the fossa ovalis. Few (14%) originated from the LA wall, mitral valve annulus and anterior mitral leaflet. One patient succumbed to low cardiac output and another died of massive embolic stroke following surgery. There were no late deaths. Two patients (3.7%) developed left hemiparesis after operation but recovered completely. There was one (1.9%) recurrence 3 years after surgery. Atrial fibrillation occurred in one patient. Mitral insufficiency which was seen in two (3.7%) patients prior to surgery subsided following excision of the tumor. Postoperatively 94% patients remained without symptoms.

CONCLUSION

Owing to the risk of valvular obstruction or embolization early surgery is indicated. Right atrial trans-septal approach is safe and easy. Most patients are asymptomatic following surgery. A yearly follow-up is essential.

A study of serum lipid profile and serum apolipoproteins A1 and B in Indian male violent criminal offenders

BACKGROUND

High cholesterol has been advanced as the most important factor in the development of coronary artery disease. Most panels have recommended population-wide dietary restrictions, yet a body of evolving data yields evidence of the hazards of low cholesterol, including links to aggression and hostility.

OBJECTIVES

The aim of this study was to compare the serum lipid profile and serum apolipoproteins A1 and B of men with a violent criminal record and men with no criminal history.

METHOD

Fasting blood samples were collected from 30 men with a known history of violent crime and 30 men with no criminal record. Serum lipid profile and serum apolipoproteins A1 and B were measured in each sample, and compared between the two groups.

RESULTS

The group with the violent criminal record showed significantly lower total cholesterol, lower LDL cholesterol, higher apolipoprotein A1 and lower apolipoprotein B compared with the control group.

CONCLUSION

Lower total cholesterol, lower LDL cholesterol, higher apolipoprotein A1 and lower apolipoprotein B could predispose to violence. Future research might explore the possibility that diets offered in prison could affect relevant pathways in lipid metabolism.

Psychosocial dysfunction and family burden in schizophrenia and obsessive compulsive disorder

This study aimed to assess and compare the extent and pattern of psychosocial dysfunction and family burden in schizophrenia and obsessive-compulsive disorder, and to identify interrelationships between the two variables in these two disorders. First-degree relatives/spouses of 35 schizophrenic and 30 OCD patients were interviewed using the Dysfunction Analysis Questionnaire (DAQ) and the Family Burden Interview Schedule (FBIS). Global score and scores in vocational, personal, familial and cognitive areas on the DAQ, and global score, subjective score, and scores on items such as financial burden, disruption of family-routine, disruption of family leisure and disruption of family interactions on the FBIS were significantly higher in the schizophrenic group. Dysfunction in social area was comparable in two groups. OCD group showed a significant positive correlation between dysfunction and all areas of family burden except physical and mental health. Schizophrenic group showed a significant positive correlation between dysfunction and disruption of family interaction. The implications of these findings are discussed.

Marriage consummated after 22 years: a case report

This case report discusses a couple who presented with a 22-year unconsummated marriage, due to penetration phobia in the female partner. The couple did well with sex education and therapy. The case is discussed in its various aspects and with a cultural background.

Ect in mentally retarded subjects with psychiatric illness

The mentally retarded subjects show a much higher prevalence of full range of psychiatric disorders than the non-retarded population. Whereas the role of psychotropic drugs in such patients is well discussed, the reports on the use of ECT are scarce. Many psychiatrists dealing with the mentally retarded psychiatric patients are reluctant to consider ECT due to lack of adequate experience. We report five mentally retarded patients with different psychiatric disorders who were successfully treated with ECT after failing adequate trials of pharmacotherapy. No disproportionately higher adverse events on account of mental retardation were observed. ECT need to be favorably considered in mentally retarded persons with psychiatric morbidity especially when treatment with psychotropic drugs either fail or is intolerable.

Normal pressure hydrocephalus presenting as psychotic depression : moderately successful treatment with a course of ect & pharmacotherapy : a case report

The characteristic symptoms of normal pressure hydrocephalus are dementia, urinary incontinence and gait disturbance. Psychiatric symptoms make their appearance usually after the characteristic symptoms. In some cases, however, prominent psychiatric symptoms are the presenting picture even before the cognitive decline is evident. A case of NPH is discussed which presented with psychotic depression along with urinary incontinence. CT scan showed dilated supratentonal ventricular system and normal fourth ventricle. There was slight widening of cortical sulci. The cognitive impairment set in later during the course of illness. The psychiatric symptoms responded fairly well to a course of ECT and antidepressant drugs.

Electro convulsive therapy in pre-pubertal catatonia: a case study

Depression in prepubertal age group is a relatively rare condition. The presence of life threatening catatonic features call for aggressive treatment. Electro convulsive therapy (ECT) has been described to be effective in these circumstances; however, doubts have been raised about its safety profile. This present case study illustrates the efficacy and safety of ECT in prepubertal catatonia.

Neurobilogy of asperger's syndrome : a case study and overview

Asperger's syndrome is an autistic spectrum disorder, which has engendered lesser attention in comparison to autism. Recent literature has focused on the involvement of cortical areas of the brain in this syndrome. We report a case of Asperger's syndrome in which an extensive work-up, including neuropsychological, neurophysiological and neuroimaging procedures, were undertaken. The findings of the various investigative procedures are discussed and literature supporting the neurobiological basis of Asperger's syndrome is highlighted. Finally, we briefly touch upon the 'Theory of Mind' construct in autistic spectrum disorders.

Ganser'S syndrome : a report of two unusual presentations

Ganser's syndrome is a rare and controversial entity in psychiatric nosology. We report two cases ofGS, one developing in a 12-year-old boy, which had their onset during an episode of mania. After recovery from Ganser's syndrome, these cases were followed-up for two and five years, respectively. Interestingly both these patients evolved into bipolar disorder with one patient showing recurrence of Ganser symptoms with each subsequent episode. The importance of following-up and relevance of affective symptoms in GS is discussed.

Childhood leukodystrophy presenting as secondary bipolar disorder

Leukodystrophies are rare dysmyelinating disorders of the nervous system, which occasionally have an initial psychiatric presentation. This report describes a case of a 9-year-old boy whose initial presentation resembled a bipolar disorder but subsequent work-up revealed an underlying leukodystrophy, most likely Alexander's disease. The course of this rare disease along with the implications of making a diagnosis of leukodystrophy in a psychiatric setting is discussed.

Phenomenology of mania - a factor analysis approach

The phenomenology of mania has not been empirically studied adequately. Various studies have revealed 2. 4 & 5 factors as the core features defining the manic state. Differences in the Bipolar disorders have been reported across culture in the past further complicating the issue.This study was carried out to study the core features of the manic state and compare it with similar studies across culture.Hundred consecutive patients attending the Central Institute of Psychiatry's Out Patient Services for the first time with a diagnosis of manic episode or bipolar disorder, current episode mania as per Diagnostic Criteria for Research were taken up for the study.Factor analysis using Principal Components with Varimax rotation was carried out. Factor score were tested for normal distribution using Kolmogorov Smirnov statistic.The findings revealed three factors representing psychomotor acceleration, thought disorder and mood All distributions were normal. Mood was found to be on a continuum with euphoria and irutability on the opposite poles.

Lithium toxicity - a descriptive study

Lithium is the treatment for acute mania and bipolar disorders. Ever since its introduction in the psychiatric arsenal, case reports of toxicity have been appearing in the literature at regular intervals. This study was thus carried out to study the presentation and associated features of lithium toxicity. In this retrospective study, case record files of all patients suspected to have developed lithium toxicity during a five year period were retrieved. It was found that toxicity presented most commonly with cerebellar symptoms and appeared at lower serum levels. Lithium could be restarted albeit at a lower dose and with a gradual titration in a number of cases.

Gender difference in resolution of mania

Gender differences are being increasingly reported across psychiatric disorders. Females are known to be more at risk for developing unipolar depressive disorders. In bipolar disorder there is more dysphoria, rapid cycling and more number of depressive episodes in females. However studies on gender difference in resolution are scarce. This study was conducted in Central Institute of Psychiatry to assess the gender difference in resolution of mania. 24 males and 16 females were rated at day 0, 3, 7, 14, 21 & 28 on scale for Manic States, ft was found that males settled faster than females, which was evident at day 14. The rate of resolution was more in males in the first week. Remission was also reached earlier by males.

Post-encephalitic Kluver-Bucy syndrome

Kluver-Bucy syndrome is a rare amalgamation of neurobehavioural signs and symptoms seen infrequently in humans following insult to bilateral temporal lobes. This report presents a case which along with emerging symptoms of Kluver-Bucy syndrome, developed Attention-Deficit/Hyperactivity Disorder (ADHD) consequent to viral encephalitis. The case highlights the presentation and management of this syndrome in a six-year-old girl with primary focus on the implications of Kluver-Bucy symptoms in current clinical practice involving neurobehavioural syndromes in children.

Psycho-social dysfunctions in patients after recovery from mania and depression

Contrary to popular opinion, complete functional recovery does not occur in approximately 25% of patients with a diagnosis of mood disorders. The current study aimed at finding the recovery status in major mood disorders. A sample group of 122 patients (77 bipolar and 45 major depression) was selected from the outpatient department, fulfilling the DSM-IV diagnostic criteria. All patients had their index episodes at least one year prior to their date of inclusion and were either asymptomatic or mildly symptomatic during that time. Manics and depressives were rated with the Bech Raefelson Mania Scale (BRMS) and Hamilton Depression Rating Scale (HDRS) respectively. All the patients were also rated on the Brief Psychiatric Rating Scale (BPRS), Dysfunction Analysis Questionnaire (DAQ) and Global Evaluation Scale of Disability Assessment Schedule by WHO (GES/DAS). They were compared with 40 age and sex matched normal controls. It was found that the symptomatic recovery was better than the functional recovery in both manics and depressives and patients with major depression were marginally more dysfunctional compared to those with mania. It is concluded that a majority of patients of both mania and depression do not achieve complete functional recovery and are in need of on-going psychosocial rehabilitation.

Lithium neurotoxicity at therapeutic level--a case report

A 30 years old Hindu male presenting with symptoms of lithium toxicity. On investigation, serum lithium level was found to be 0.5 meq/l. Though toxicity at this level of lithium is unusual, still neurotoxicity happened to be the cause of his hospital admission. He was debarred from taking lithium further and carbamazepine was started as mood elevator. He responded favourably.

Secondary gender identity disorder - a case report

An eighteen year old Christian male, diagnosed as Bipolar Affective Disorder, 2nd manic episode with mood congruent psychotic features presented during the episode with the explicit wish for sex reassignment surgery. He even claimed to be married to a local man. With effective management of the manic episode, his wish for sex reassignment surgery has completely subsided. This report discusses the literature regarding secondary gender identity disorder occurring in psychotic conditions and further implications of the same.

A comparison of stapled vs handsewn anastomosis in anterior resection for carcinoma rectum

The merits of stapled versus hand sewn anastomosis were evaluated in a prospective randomized study of 60 patients undergoing resection for rectal cancer. The analysed factors included the time required for construction of anastomosis, post operative complications, local recurrence, disease free state and survival. Hand sewn anastomosis was performed in two layers with 3/0 silk in 30 cases and the stapled anastomosis with EEA staplers in 30 cases. The anastomosis time averaged 24 minutes in the suture group and 16 minutes in the stapling group. Five post-operative complications occurred in each group. Six patients of the hand sewn group developed local recurrence as a first sign of treatment failure compared to four patients in the stapled group. The average time of study was 41 months. No significant difference was found in the overall survival pattern of the two groups.

Multifocal leucoencephalopathy presenting as antidepressant induced mania

A male patient presented with tricyclic induced hypomania after treatment for chronic depression. On follow up the patient deteriorated towards dementia with multifocal leucoencephalopathy. The possible role of brain lesions in the causation of affective syndromes and the neurobiological hypothesis of bipolar syndromes are discussed. The authors propose that chronic depression should be thoroughly investigated for a probable Axis III diagnosis.

Gastric cancer: a critical analysis of surgical treatment and long term survival

Results of consecutive study of 120 cases of carcinoma stomach treated by one surgical team over a period of 10 years (1980-89) are presented. Maximum cases were in the sixth and seventh decades with male to female sex ratio of 2.5:1. The lesion in most cases were in the gastric antrum. Distal tumours were more of poorly differentiated histology compared to proximal tumours. Eighty-three out of 120 (69%) patients underwent surgical resection. In 50 patients it was in the form of a subtotal and distal gastrectomy. Only 5 patients underwent a total gastrectomy. In 70 cases the resection which involved en bloc removal of involved part of stomach including adequate proximal and distal free margins, omenta and perigastric lymph nodes and considered absolutely curative in 8 cases being no disease. The overall 5-year-survival figure was 18%. However, taking only the resected cases into account, the 5-year survival rate was 27%. The low survival figure can be attributed to a very small number of early cases encountered.

Consistency of delusions in schizophrenia and affective disorder

The content of delusions were studied in a group of schizophrenics and affective disorder patients who had an episodic course to ascertain if the content of delusions remained similar or became dissimilar during different episodes. There were 18 schizophrenics and 30 affective disorder cases in this study. Consistency of delusional content was noted in one third of the cases in each group. Delusional content was consistent over episodes more often in Hindus (P less than 0.04), those married (P less than 0.03), and those from a rural background in the schizophrenic group. These differences were not observed in the affective disorder cases. Possible reasons for the consistence or non-consistence of delusional content are discussed.

Recurrence of hallucinations in consecutive episodes of schizophrenia and affective disorder

48 patients with episodic psychosis (18 schizophrenia, 30 MDP) were studied to examine whether they had similar hallucinations in consecutive episodes. 34 cases reported hallucinations, 23 of whom had hallucinations in consecutive episodes. In 22 of these 23 cases, the same type of hallucination (in the same sense organ modality) recurred. A recurrence of similar content was found in nearly half of the cases. In cases in whom the hallucinatory content persisted, however, there was no persistence of delusional content. Similar neurophysiological disturbances in similar neuroanatomical regions may result in the persistence of the same hallucinations.