Scale for retrospective assessment of immediate concussion symptoms.

The retrospective diagnosis of concussion is often missed by clinicians. We present a brief scale for retrospective assessment of the immediate concussion symptoms (ICS) to facilitate the diagnosis of patients without visible head injury or full loss of consciousness. We administered the scale to 90 survivors of car accidents (mean age 42.0, SD=13.6; 33 males, 57 females) at 2 to 33 months after their accident. Our scale consists of 6 items and these were endorsed by the following % of our respondents: feeling dazed (64.4% of our 90 respondents), stunned (73.3%), confused (70.0%), disoriented (62.2%), dizzy (57.8%), and loss of consciousness (22.2%). The statistical properties of the scale are satisfactory (Cronbach alpha = 0.74). The scale correlates with post-accident insomnia (r=0.28), depression (r=0.29), and also with Rivermead measure of the chronic post-concussion syndrome (r=0.34). The ICS scale could be used as a starting point in longitudinal research with brain imaging procedures to evaluate the stages of recovery from the initial concussion. Attached are the English, Spanish, French, German, Italian, Russian, and Czech versions of our scale.

Are burnout prevention programs for hospital physicians needed?

INTRODUCTION: Burnout, whether as a brief episode or more protracted, affects all aspects of a physician's life. Given the critical role of physicians in society, efforts to monitor, preserve, and enhance physician health are beneficial also to their patients. We investigated the patterns of burnout in physicians. METHODOLOGY: Maslach Burnout Inventory (MBI), in the General Survey version, was handed out to interested physicians of a Canadian general hospital in a Grand Rounds lecture on "well-being of physicians." They were to complete the MBI on an anonymous basis. Fifty-five adequately completed questionnaires were received. RESULTS: Our physicians obtained significantly higher (p<0.01) average score on Emotional Exhaustion subscale of MBI (14.0, SD=7.5) and on the Cynicism subscale of the MBI than average scores from combined 9 occupational samples listed in Maslach's manual: our physicians reported more intense emotional depletion and endorsed more items suggestive of cynicism. However, their average Professional Efficacy score (27.6, SD=6.3) did not significantly differ from Maslach's combined average for this subscale. The physicians' Professional Efficacy scores were not significantly related to those of Emotional Exhaustion and of Cynicism (Pearson coefficients, p>0.05). CONCLUSIONS: This suggests that improving professional medical skills (and thus a sense of efficiency) alone cannot prevent physicians from burnout. An implementation of other preventive strategies such as those based on mindfulness or on cognitive behaviour therapy (CBT) is necessary.

Lady with Erotic Preference for Diapers.

A patient in her 20s was referred to us for psychological assessment due to her depression and suicide attempts. She mentioned being anorgasmic except when diapered and emphasized her erotic preference for diapers. Her childhood included maternal deprivation in an impecunious family headed by an irritable physically disabled father on social assistance. Given the maternal deprivation in childhood, her erotic fixation on diapers parallels the emotional attachment to diapers observed by Harlow in mother deprived infant monkeys. Etiological hypotheses should also include the paradigm of avoidance learning from theories of behavior therapy. Our patient does not wish to change her sexual preference: in such cases, fetishism is not considered as an illness by DSM5. However, she needs to be treated for pathological levels of depression with suicidal ideation and low self-esteem.

Body Composition Changes Associated With Methadone Treatment.

BACKGROUND: Methadone is associated with a statistically significant increase in BMI in the first 2 years of treatment. OBJECTIVES: To evaluate the changes of body composition (bone mass, % fat, % muscle mass, % water, and basal metabolic rate) related to this increase. PATIENTS AND METHODS: Changes in body composition were monitored, via bioelectrical impedance, in 29 patients in methadone treatment for opiate dependency (age 18 to 44, mean = 29.3, SD = 7.0, 13 men, 16 women). RESULTS: Within one year from admission to treatment, a statistically significant (t-tests, P < 0.05) increase was noted in their body mass index (BMI), % of body fat, average body mass, and average basal metabolic rate, and relative decrease in their % of muscle mass and % of bone mass. Neither absolute bone mass nor muscle mass changed significantly. CONCLUSIONS: Physicians involved in care of methadone patients should recommend dietary and lifestyle changes to improve their overall health.

Fetishistic Preferences of Clients as Ranked by a Sex Worker.

A former escort girl and stripper, now retired and in her forties, of intelligence at the level comparable to that of university graduates, was interviewed about unusual sexual requests of her former clients. She reported that most frequent requests were (1) those involving a foot or shoe fetish, (2) those to sell to the male client her underwear, and (3) those to urinate into her underwear before selling it to the client.

Reactions of Psychiatric Patients to Telepsychiatry.

Telepsychiatry could offer a viable medical service to remote or isolated social communities if it does not generate adverse reactions such as delusional ideation, particularly in patients in settlements without adequate exposure to mainstream culture and internet. We examined subjective reactions to telepsychiatry of randomly selected 84 psychiatric patients from remote locations in Ontario, Canada. They rated the quality of their teleconferencing sessions via 10 item questionnaire and were asked about advantages and disadvantages of telepsychiatry. The majority of patients indicated that they were able to communicate as if physically present (92.9%) and were comfortable with telepsychiatric service (95.2%). They found the sessions as beneficial as direct meetings with their psychiatrist (84.5%) and would use this service again (98.8%). There were no instances of telepsychiatry being associated with adverse reactions in patients from remote communities with inadequate exposure to modern mainstream culture and internet.

SELF-REPORTS OF ILLEGAL ACTIVITY, SCL-90-R PERSONALITY SCALES, AND URINE TESTS IN METHADONE PATIENTS.

In routine work, medical staff usually has to rely on the patient's self-reports of criminal activity and of recent involvement in fights. This study examines how these self-reports of crime correlate with the patients' routine urine tests and personality measures. Pearson correlations of these self-reports by 55 methadone patients (M age = 34.1 yr., SD = 9.1; 35 men, 20 women) were calculated to their urine screening tests (those for opiates, benzodiazepines, and cocaine) and to personality scores on the Symptom Checklist 90-Revised (SCL-90-R). Patients who reported being involved in recent illegal activities to obtain drugs had significantly higher scores on the SCL-90-R scale assessing obsessive-compulsive symptoms (r = .28) and had more frequent positive urine tests for cocaine (r = .35). Those who reported having engaged in fights within the last 12 mo. had higher scores on SCL-90-R measures of somatic complaints (r = .32), anxiety (r = .31), and depression (r = .29), and of overall psychopathology (r = .29), and they also had more often positive urine tests for cocaine (r = .28) than other patients. Studies on larger samples are needed to help clinicians to predict criminal or hostile behavior during methadone treatment.

Psychopathology and Urine Toxicology in Methadone Patients.

Several studies reported high rates of psychiatric commorbidity among methadone patients. We examined the relationships of measures of psychopathology to outcomes of screening urine tests for cocaine, opiates, and benzodiazepines in a sample of 56 methadone patients. They also completed the Symptom Check List-90-Revised (SCL-90-R). The highest scales in the SCL-90-R profile of our patients were those indicating somatic discomfort, anger, phobic anxiety, paranoid ideation, and also obsessive-compulsive disorder symptoms (scores above the 39(th) percentile). The only significant correlations between urine tests and SCL-90-R psychopathology were those involving benzodiazepines: patients with urine tests positive for benzodiazepines had lower social self-confidence (r=0.48), were more obsessive-compulsive (r=0.44), reported a higher level of anger (r=0.41), of phobic tendencies (r=40), of anxiety (r=0.39), and of paranoid tendencies (r=0.38), and also reported more frequent psychotic symptoms (r=0.43).

The role of nutrient-based epigenetic changes in buffering against stress, aging, and Alzheimer's disease.

Converging evidence identifies stress-related disorders as putative risk factors for Alzheimer Disease (AD). This article reviews evidence on the complex interplay of stress, aging, and genes-epigenetics interactions. The recent classification of AD into preclinical, mild cognitive impairment, and AD offers a window for intervention to prevent, delay, or modify the course of AD. Evidence in support of the cognitive effects of epigenetics-diet, and nutraceuticals is reviewed. A proactive epigenetics diet and nutraceuticals program holds promise as potential buffer against the negative impact of aging and stress responses on cognition, and can optimize vascular, metabolic, and brain health in the community.

Proof-of-Concept Randomized Controlled Study of Cognition Effects of the Proprietary Extract Sceletium tortuosum (Zembrin) Targeting Phosphodiesterase-4 in Cognitively Healthy Subjects: Implications for Alzheimer's Dementia.

Introduction. Converging evidence suggests that PDE-4 (phosphodiesterase subtype 4) plays a crucial role in regulating cognition via the PDE-4-cAMP cascade signaling involving phosphorylated cAMP response element binding protein (CREB). Objective. The primary endpoint was to examine the neurocognitive effects of extract Sceletium tortuosum (Zembrin) and to assess the safety and tolerability of Zembrin in cognitively healthy control subjects. Method. We chose the randomized double-blind placebo-controlled cross-over design in our study. We randomized normal healthy subjects (total n = 21) to receive either 25 mg capsule Zembrin or placebo capsule once daily for 3 weeks, in a randomized placebo-controlled 3-week cross-over design. We administered battery of neuropsychological tests: CNS Vital Signs and Hamilton depression rating scale (HAM-D) at baseline and regular intervals and monitored side effects with treatment emergent adverse events scale. Results. 21 subjects (mean age: 54.6 years ± 6.0 yrs; male/female ratio: 9/12) entered the study. Zembrin at 25 mg daily dosage significantly improved cognitive set flexibility (P < 0.032) and executive function (P < 0.022), compared with the placebo group. Positive changes in mood and sleep were found. Zembrin was well tolerated. Conclusion. The promising cognitive enhancing effects of Zembrin likely implicate the PDE-4-cAMP-CREB cascade, a novel drug target in the potential treatment of early Alzheimer's dementia. This trial is registered with ClinicalTrials.gov NCT01805518.

WITHDRAWN:A Validation Study of the International Consensus Diagnostic Criteria for Neuroleptic Malignant Syndrome.

Ahead of Print article withdrawn by publisher.

Wait time impact of co-located primary care mental health services: the effect of adding collaborative care in northern Ontario.

OBJECTIVES: In the shared care model, psychiatrists and physicians work in the same office areas, write their notes in the same casebooks, and can more rapidly exchange information about referrals and health conditions of their patients. We evaluated the impact of the introduction of a shared mental health care service, co-located with a primary care site, on wait times for mental health services in a northern Ontario city. METHOD: Chart reviews were conducted to examine a total of 3589 referrals for 5 mental health outpatient services (1 shared care and 4 existing services) from January 2001 to the end of June 2004. The shared mental health care service site was started in July 2001. Wait time was measured 6 months prior to and up to 3 years after the introduction of the shared care service. RESULTS: The shared care site offered services more than 40 days sooner and also helped to reduce wait time on the nonshared care sites. After shared care began, the pre-existing, nonshared care services had wait times of about 13 days shorter during the 3 subsequent years. CONCLUSIONS: The shared care service maintained the lowest overall wait times, compared with the existing nonshared care services. The existing services experienced a decrease in the number of days waiting when the baseline wait time was compared with that of the following year.

Suicidality in a sample of Arctic households.

We investigated the association of suicidal ideation and behavior with depression, anxiety, and alcohol abuse in a Canadian Arctic Inuit community. Inuit (N = 111) from a random sample of households completed assessments of anxiety and depression, alcohol abuse, and suicidality. High rates of suicidal ideation within the past week (43.6%), and suicide attempts within last 6 months (30%), were reported. Ideation was more frequent among younger persons, whereas those favoring local native language were less likely to report a wish to die. Higher overall suicidality scores were associated with higher anxiety, and alcohol abuse, but not with depression or gender. Implications for future research are discussed.

Autonomic signs and dosing during the initial stages of clozapine therapy.

BACKGROUND: Recent reports implicate clozapine in heart rate variability, QTc prolongation, torsade de pointes and sudden death at therapeutic doses, even in physically healthy patients. This study aims to examine whether autonomic (vital) signs are correlated with clozapine dose titration and blood levels of clozapine and nor-clozapine during clozapine therapy. MATERIAL/METHODS: Thirty-seven consecutive patients with diagnosis of schizophrenia treated with clozapine were included in this prospective longitudinal study. The study was restricted to only the first 8 weeks of treatment. After obtaining informed consent, serum concentrations of clozapine and nor-clozapine were determined weekly at trough, as doses were administered q12h and adjusted according to clinical guidelines for clozapine use. Autonomic signs including BP (supine and erect), pulse (supine and erect) and temperature were monitored daily each morning before and one hour after the morning's dose of clozapine was administered. RESULTS: We calculated analyses of covariance (ANCOVAs) to evaluate the changes in vital signs parameters, from baseline to week 8, with clozapine variables as covariates (i.e, the dose of clozapine, as well as the levels of serum clozapine and nor-clozapine). The blood pressure and pulse did not change significantly (p<0.01) from baseline to weeks 8. The temperature was inversely related to clozapine dose (p<0.003). Higher nor-clozapine to clozapine ratios were associated with higher BP measures (p=0.002). The magnitude of these relationships is weak (r<0.30). CONCLUSIONS: There is a tendency to autonomic dysregulation during clozapine use. This has cardiac function implications, justifying cautious dose adjustment with frequent monitoring of vital signs.

Clinical correlates of insight in schizophrenia.

111 schizophrenic patients diagnosed in accordance with DSM-III were rated on Landmark's symptom checklist, on demographic variables, and on variables descriptive of the course of illness. Of the 111 patients, 108 (97.3%) showed poor insight into their illness at some time in the past and 65 (58.6%) at the time of assessment. Those presently showing poor insight were significantly (Pearson rs, p< .01, 2-tailed) more frequently rated as currently displaying poor judgement also in other matters (r =.50), as showing social withdrawal (r=.42) and poor rapport (r=.33), and as being preoccupied with their delusions or hallucinations (r=.31) and as being unreliable informants (r=.41). They usually had lower education (r=.33), their income in the last taxation year was lower (r = .47), and their work functioning was less adequate (r = .30).

Edad de inicio y modelos clínicos en la Esquizofrenia

Se estudio la relación existente entre la edad de inicio (E.I.) y los modelos clínicos en 112 pacientes diagnosticados de esquizofrenia según los criterios DSM III. Empleamos los coeficientes de correlación para controlar la duración de la enfermedad y evitar así el factor de confusión de la cronicidad. Los pacientes con inicio tardío de la enfermedad presentaron un mayor número de delirios paranoides aunque mostrando problemas relacionados con la volición (pérdida de la iniciativa o energía) en menos ocasiones. Estos pacientes con inicio tardío de la enfermedad tenían una mayor tendencia a presentar síntomas de otro tipo de enfermedad mental distinta a la esquizofrenia. Todas las correlaciones fueron débiles (los valores absolutos deriban de ,21 a ,24, p < ,05) y no superarían la corrección de Bonfernoni (AU)

Relation of blood counts during clozapine treatment to serum concentrations of clozapine and nor-clozapine.

OBJECTIVE: To determine the relation between serum clozapine and nor-clozapine levels and blood cell counts during clozapine treatment. METHOD: We undertook a prospective longitudinal study of 37 consecutive patients with a diagnosis of schizophrenia treated with clozapine. We obtained informed consent and then determined serum concentrations of clozapine and nor-clozapine weekly. Clozapine was administered daily in divided doses given every 12 hours and adjusted according to clinical guidelines for its use. Samples for serum concentrations were taken at steady state, immediately before the next morning's dose, for 4 to 8 weeks. Complete blood counts (CBC), weight, and vital signs (that is, blood pressure, pulse, and temperature) were also monitored weekly before the morning's dose of clozapine was administered. RESULTS: Analyses of variance showed no significant changes over the 8-week treatment course in the observed mean white blood count (WBC), red blood count (RBC), neutrophils, and lymphocytes counts, or in the hemoglobin and hematocrit. Only a few weak correlations (r < 0.21) were found between these hematological parameters and the measures of serum clozapine and nor-clozapine. CONCLUSIONS: The mechanism of clozapine-induced hematotoxicity at the therapeutic dosage range is probably not by direct toxicity of clozapine or nor-clozapine to the blood cells or their precursors. The formation of the cytotoxic nitrenium compound from clozapine by neutrophils may be necessary.

A frequent misunderstanding associated with point biserial and phi coefficients.

The label "Pearson r" is legitimately used both for the standard Pearson r calculated on continuous variables and for its other varieties in the form of the point biserial or the phi coefficient. This fact is often ignored by psychologists and psychiatrists.

Sociodemographic correlates of assimilation of refugees from Kurdistan.

Successful assimilation of refugees in their host country is an important prerequisite of psychological well-being. Refugees' satisfaction in the new country is one of key indicators of their assimilation. The satisfaction with their host country was assessed for 54 Kurdish refugees of mean age of 35.8 yr. (SD= 10.9) via an 8-item rating scale partly based on Cernovsky's Assimilation Scale. The 36 men and 18 women had resided in the host country for a mean of 4.5 yr. (SD=4.0). An overall score was calculated from ratings of satisfaction with personal safety, health, employment, food, financial security, social life, and entertainment. This overall score was unrelated to age, sex, and employment status. Those who emigrated at a younger age (r = -.28, p = .03) and those with lower education reported more satisfaction with their host country (r = -.28, p = .03) perhaps because they could more easily and rapidly re-establish social status comparable to what they had in their homeland than could older refugees from Kurdistan's higher educational strata.