Genital tuberculosis--a major pelvic factor causing infertility in Indian women.

OBJECTIVE: To study the effect of tuberculosis, a common infectious disease in the Indian subcontinent, on the female pelvic factor and its subsequent effect on female fertility. DESIGN: Retrospective case studies. SETTING: Department of Infertility Management and Assisted Reproduction, Jaslok Hospital and Research Centre, Bombay, India. PATIENT(S): Three hundred women, between the ages of 25 and 35 years, with tubal factor as a cause of their infertile state. RESULT(S): One hundred seventeen women with a tubal factor were found to have tuberculosis as the cause of tubal blockage. On laparoscopy, 49.5% were found to have simple tubal blockage, 15.3% showed tubo-ovarian masses, and 23.9% had a frozen pelvis. Seventy-five percent complained of menstrual irregularities, thus indicating endometrial involvement; 25.6% of these women underwent an IVF procedure. The pregnancy rate after IVF-ET was 16.6% per transfer. CONCLUSION(S): This study highlights the fact that tuberculosis, a chronic infectious disease, is one of the major etiologic factors of female tubal infertility, especially on the Indian subcontinent.

Assisted hatching in an in vitro fertilization programme.

Assisted hatching was performed on 37 women (IVF, n = 12; micromanipulation, n = 25), who were at risk of poor implantation after in vitro fertilization and micromanipulation, and who had previous cycles of failed implantation. A total of 292 oocytes was retrieved (7.9 per cycle) of which 90 were subjected to IVF and 202 were micromanipulated. Assisted hatching was performed on day 3 of culture, on six- to eight-cell embryos, by the technique of mechanical partial zona dissection. All the patients undergoing the procedure of assisted hatching had embryos with thick zonae, greater than 15 microns. Assisted hatching was performed on 39 embryos (55.7%) in the IVF group and 104 embryos (77.6%) in the micromanipulation group. The damage rate after hatching was 1.4%. The pregnancy rate per cycle was 50% in the IVF group and 44% in the micromanipulation group, compared with 10% (IVF) and 19.2% (micromanipulation) in the control groups. Assisted hatching, by partial zona dissection, results in significant improvement in pregnancy rates in women more than 38 years of age, who have a thick zona and with previous poor implantation results. This paper reports the first pregnancy in India by the technique of assisted hatching (partial zona dissection).

Pathological laughing and crying following stroke: validation of a measurement scale and a double-blind treatment study.

OBJECTIVE: This study was undertaken to test the reliability and validity of the Pathological Laughter and Crying Scale and the effectiveness of nortriptyline treatment for patients with emotional lability following stroke. METHOD: Eighty-two patients with ischemic brain injury-54 who had been hospitalized with acute stroke and 28 others who requested treatment for pathological laughing and crying--were given standardized psychiatric and neurological assessments and then administered the Pathological Laughter and Crying Scale. The 54 acute stroke patients were used to evaluate the Pathological Laughter and Crying Scale, and the 28 patients with pathological emotional display were randomly assigned to nortriptyline treatment or placebo in a 6-week double-blind trial to assess the efficacy of a tricyclic antidepressant in treatment of this disorder. RESULTS: The interrater reliability on the Pathological Laughter and Crying Scale for a subgroup of 15 patients was 0.93, and the test-retest reliability of the scale was excellent. After 4 and 6 weeks of treatment, scores on the Pathological Laughter and Crying Scale showed significantly greater improvement in the 14 patients given nortriptyline than in the 14 given placebo. Although almost one-half of these patients also had major depression, the improvement in emotional lability was independent of depression status. In addition, response to treatment was not significantly affected by lesion location or time since stroke. CONCLUSIONS: The severity of symptoms in pathological emotional display can be reliably quantified with the Pathological Laughter and Crying Scale, and treatment with nortriptyline can effectively ameliorate this emotional disorder.

Reduction of CSF monoamine metabolites in poststroke depression: a preliminary report.

Monoamine metabolites were measured in the cerebrospinal fluid (CSF) of depressed and nondepressed patients with acute stroke lesions and in nondepressed patients without stroke lesions. Depressed stroke patients had a significantly lower concentration of CSF 5-hydroxyindoleacetic acid (5-HIAA; a serotonin metabolite) than the other two groups. These findings suggest that poststroke depression may be mediated by serotonergic mechanisms.

Are depressive symptoms nonspecific in patients with acute stroke?

OBJECTIVE: Some investigators have suggested that major depression might be overdiagnosed in stroke patients because of changes in appetite, sleep, or sexual interest caused by their medical illness; others have suggested that depression may be underdiagnosed in stroke patients who deny symptoms of depression because of anosognosia, neglect, or aprosody. The authors' goal was to determine how frequently depressive symptoms occur in acute stroke patients with and without depressed mood to estimate how often diagnostic errors of inclusion or exclusion may be made. METHOD: They examined the rate of autonomic and psychological symptoms of depression in 205 patients who were consecutively hospitalized for acute stroke. Eighty-five (41%) of these patients had depressed mood, and 120 (59%) had no mood disturbance. Forty-six (54%) of the 85 patients with depressed mood (22% of all patients) were assigned the DSM-III diagnosis of major depression. RESULTS: The 120 patients without mood disturbance had a mean of one autonomic symptom, but the 85 patients with depressed mood had a mean of almost four. Tightening the diagnostic criteria to account for one more nonspecific autonomic symptom decreased the number of patients with major depression by only three; adding two more criteria decreased the number by only five. Thus, the rate of DSM-III major depression was 1% higher than the rate with one extra nonspecific autonomic symptom and 2% higher than the rate with two extra criteria. Conversely, loosening diagnostic criteria to account for denial of depressive illness increased the rate of major depression by only 5%. CONCLUSIONS: Both autonomic and psychological depressive symptoms are strongly associated with depressed mood in acute stroke patients.

Spontaneous remission of post-stroke depression and temporal changes in cortical S2-serotonin receptors.

A patient with post-stroke depression following infarction of the left basal ganglia is described. The patient's depression remitted during a 6-week double-blind treatment trial while receiving placebo medication. Cortical S2-receptor binding that was measured using 11C-N methyl spiperone and positron emission tomography (PET), increased in the left temporal cortex by more than 25% during the treatment trial. The change in serotonin receptor binding and its relationship to the improvement in mood observed in this patient are consistent with previously published data demonstrating a correlation between serotonin receptor binding in the left temporal cortex and severity of symptoms of depression.

The impact of poststroke depression on recovery in activities of daily living over a 2-year follow-up.

The impact of clinically diagnosed depression on recovery in activities of daily living over a 2-year follow-up was examined in a prospective study of 63 stroke patients. Although impairment in activities of daily living, neurologic diagnoses and findings, lesion location and volume as measured on computed tomographic scan, demographic variables, cognitive impairment, and social functioning were comparable between depressed (n = 25) and nondepressed (n = 38) patients during their acute hospitalization, the two groups had different patterns of recovery in activities of daily living. At 2 years after suffering a stroke, patients with an in-hospital diagnosis of depression (either major or minor depression) were significantly more impaired in both physical activities and language functioning than were non-depressed patients. Among patients with major depression, this disparity in the recovery profile was present even after the depression had remitted. This study emphasizes the need for early recognition and treatment of poststroke depression.

Relationship between anxiety disorders and depressive disorders in patients with cerebrovascular injury.

The interaction between anxiety disorder and major depressive disorder in patients with cerebrovascular lesions was examined in a controlled, 2 x 2 study design. A consecutive series of 24 patients who met criteria for major depression only were compared with 6 patients who met criteria for both major depression and generalized anxiety disorder, and 45 patients who did not meet criteria for either major depression of generalized anxiety. Among patients with positive computed tomographic scans, the anxious-depressed group (n = 19) showed a significantly higher frequency of cortical lesions, while patients with major depression only (n = 15) had a significantly higher frequency of subcortical (basal ganglia) strokes. No significant between-group differences were found in other variables, such as demographic variables, familial and personal history of psychiatric disorders, and neurologic deficits. These findings suggest that, in this mostly black, low-socioeconomic-status population, cortical vs subcortical lesion location may play an important role in determining whether severe anxiety occurs in patients with post-stroke major depression.

Mood changes after right-hemisphere lesions.

Ninety-three patients with acute stroke lesions restricted to the right hemisphere were examined for the presence of mood changes. While 46 patients showed no mood changes, 19 were unduly cheerful, 17 had developed major depression, and 11 had developed minor depression. Although there were no significant between-groups differences in other demographic variables, neurological deficits, activities of daily living, cognitive impairment, or quality of social support, patients with major depression had a significantly higher frequency of familial history of psychiatric disorder and lesions of the parietal cortex than patients with either no mood change or major depression following left-hemisphere lesions. On the other hand, undue cheerfulness was significantly associated with lesions of the right frontal operculum. These findings suggest that major depression following right-hemisphere lesions may have a different aetiology and mechanism than major depression following left frontal or basal ganglia lesions.

Differential mood changes following basal ganglia vs thalamic lesions.

Patients with computed tomographic scan-verified unilateral lesions in the basal ganglia or thalamus were examined for the presence of poststroke mood disorders. Patients with left-sided basal ganglia lesions (mainly in the head of the caudate nucleus) showed a significantly higher frequency and severity of depression, as compared with patients with right-sided basal ganglia or thalamic (left- or right-sided) lesions. Results suggest that damage to biogenic amine pathways and/or frontocaudate projections may play an important role in the modulation of mood.

Lateralized effect of cerebral infarction on spinal fluid monoamine metabolite concentrations in rats.

Using a rat model of stroke, we studied the effect of unilateral middle cerebral artery ligation on cerebrospinal fluid monoamine metabolites at different intervals over a 40-day postoperative period. Male Sprague-Dawley rats were divided into four groups: an unoperated control group (n = 9), a sham-operated group (n = 9), a right middle cerebral artery ligation group (n = 10), and a left middle cerebral artery ligation group (n = 10). One hundred microliters of cerebrospinal fluid were collected percutaneously from the cerebellomedullary cistern just before and 5, 20, and 40 days after the surgical procedure. Monoamine metabolites--3-methoxy-4-hydroxyphenylglycol (MHPG), 5-hydroxy-indoleacetic acid (5-HIAA), and homovanillic acid (HVA)--were measured using high-performance liquid chromatography. MHPG concentration in the right lesion group was significantly depleted from control levels 5, 20, and 40 days after surgery. No such depletion was observed in the left lesion rats. Concentration of 5-HIAA was relatively lower at Days 5 and 20 in the right lesion group than in the left lesion group. HVA concentration did not differ among the groups at any time. Our study has demonstrated a differential effect of unilateral ischemia on cerebrospinal fluid neurochemistry in rats dependent on the cerebral hemisphere involved.

A two year longitudinal study of poststroke mood disorders: prognostic factors related to one and two year outcome.

In a prospective study of mood disorders in 103 stroke patients, we examined the predictive value of affective, cognitive, social and neurologic variables obtained in-hospital and at six months poststroke in terms of outcome as determined by the same measures at one and two years follow-up. The following factors were found to have prognostic significance: 1) Lesion Location: proximity of the lesion on CT scan to the frontal pole in patients with left anterior infarcts showed a strong positive relationship with severity of depression at one year but not at two years poststroke. 2) Affective Status: depression (in-hospital and at 6 months) strongly predicted depression at one year but not at two years poststroke. Additionally, in-hospital depression significantly correlated with physical impairment at two years, while depression at six months bore a moderate relationship to physical impairment at one year. 3) Physical Impairment: impairment in activities of daily living in-hospital bore a modest relationship to depression at one year while such impairment at six months correlated strongly with depression at both one and two years. These findings may reflect the natural course of major depression which remits between one and two years poststroke. Although stroke lesion location is the strongest predictor of subsequent depression, there appears to be a reciprocal relationship between physical impairment and depression (i.e., depression predicts impairment and impairment predicts depression). Since poststroke depressions are amenable to therapeutic intervention, these prognostic factors may have implications for the treatment and rehabilitation of stroke patients.

The sensitivity and specificity of the Center for Epidemiologic Studies Depression Scale in screening for post-stroke depression.

The present study examines the sensitivity and specificity of the Center for Epidemiologic Studies Depression Scale (CES-D) as a screening instrument for post-stroke depression. Eighty stroke patients were evaluated by a research nurse over a two-year period using the CES-D and also by a trained psychiatrist using a standardized interview for affective, cognitive, physical and social functioning. CES-D scores correlated significantly with DSM-III diagnoses of depression in-hospital and at three months, six months, and one year follow-up but not at two years follow-up, reflecting the natural course of these depressions, as well as the predictive validity of the CES-D. Furthermore, at a cut-off point of 16, the CES-D was found to have a specificity of 90 percent, a sensitivity of 86 percent and a positive predictive value of 80 percent and thus may be a potentially useful screening instrument for post-stroke depression.

Two-year longitudinal study of post-stroke mood disorders: dynamic changes in correlates of depression at one and two years.

As part of a prospective study of 103 stroke patients, we have analyzed the relation between depression and associated variables at 3 months, 6 months, 1 year, and 2 years after stroke. At all intervals up to and including 1 year poststroke, patients with left hemisphere strokes showed a strong relation between severity of depression and distance of the lesion on computed tomography scan from the frontal pole. At 2 years poststroke, this relation was no longer significant. The correlation between depression and impairment in activities of daily living peaked at 6 months and thereafter fell but remained significant at 1 and 2 years poststroke. The correlation between depression and cognitive impairment and between depression and social functioning fluctuated--with most correlations at 1 and 2 years follow-up nonsignificant. Although the conclusions that can be drawn from this study are limited by the fact that less than half of the original patients were followed up at each time, these declining correlations between depression and associated variables at 1 and 2 years follow-up may reflect the natural course of major depression which spontaneously remits between 1 and 2 years after stroke. The persisting significant association of impairment in activities of daily living with depression may reflect the effect of severe depression in sustaining and possibly retarding recovery from physical impairment.

Effects of intravenous metoclopramide in 81 patients with tardive dyskinesia.

We compared acute effects of single intravenous administrations of metoclopramide (40 mg) and placebo in a double-blind crossover study involving 81 patients with tardive dyskinesia. Metoclopramide produced significantly greater reduction in mean total Abnormal Involuntary Movement Scale score as well as in ratings for six of the seven body areas, when compared with placebo. On adjusting each patient's metoclopramide response for his or her placebo response, we found that 35 of the 81 patients had 50% or greater placebo-corrected improvement. There were no apparent clinical differences between metoclopramide responders and nonresponders. Administration of 60 mg of metoclopramide to 15 patients produced greater improvement in tardive dyskinesia as compared with 40 mg; the incidence of acute dystonia, however, jumped from 10% with 40 mg to 33% with 60 mg.