Volume loss of the medial temporal lobe structures in subjective memory impairment.

BACKGROUND/AIMS: Subjective memory impairment (SMI) has been suggested as a manifestation of Alzheimer's Disease (AD) preceding mild cognitive impairment (MCI). In this study, we determined the volumes of the hippocampus, the entorhinal cortex (EC) and the amygdala to provide biological evidence for AD in SMI. METHODS: Regional volumetric measures were manually traced on 3-Tesla MRI scans. RESULTS: Total brain volume did not differ between the groups. Individuals with SMI had reduced volumes of the hippocampus bilaterally (right p = 0.001; left p < 0.001), the bilateral EC (right p = 0.031, left p = 0.006) and the right amygdala (p = 0.01) compared to the control group. CONCLUSION: Volume reduction of bilateral hippocampus, bilateral EC and right amygdala supports the concept of SMI as a very early manifestation of AD prior to MCI. SMI may indicate awareness of a degenerative process that can still be functionally compensated.

Nucleus accumbens deep brain stimulation decreases ratings of depression and anxiety in treatment-resistant depression.

BACKGROUND: While most patients with depression respond to combinations of pharmacotherapy, psychotherapy, and electroconvulsive therapy (ECT), there are patients requiring other treatments. Deep brain stimulation (DBS) allows modulation of brain regions that are dysfunctional in depression. Since anhedonia is a feature of depression and there is evidence of dysfunction of the reward system, DBS to the nucleus accumbens (NAcc) might be promising. METHODS: Ten patients suffering from very resistant forms of depression (treatment-resistant depression [TRD]), not responding to pharmacotherapy, psychotherapy, or ECT, were implanted with bilateral DBS electrodes in the NAcc. The mean (+/-SD) length of the current episode was 10.8 (+/-7.5) years; the number of past treatment courses was 20.8 (+/-8.4); and the mean Hamilton Depression Rating Scale (HDRS) was 32.5 (+/-5.3). RESULTS: Twelve months following initiation of DBS treatment, five patients reached 50% reduction of the HDRS (responders, HDRS = 15.4 [+/-2.8]). The number of hedonic activities increased significantly. Interestingly, ratings of anxiety (Hamilton Anxiety Scale) were reduced in the whole group but more pronounced in the responders. The [18F]-2-fluoro-2-deoxy-D-glucose positron emission tomography data revealed that NAcc-DBS decreased metabolism in the subgenual cingulate and in prefrontal regions including orbital prefrontal cortex. A volume of interest analysis comparing responders and nonresponders identified metabolic decreases in the amygdala. CONCLUSIONS: We demonstrate antidepressant and antianhedonic effects of DBS to NAcc in patients suffering from TRD. In contrast to other DBS depression studies, there was also an antianxiety effect. These effects are correlated with localized metabolic changes.

Clozapine: acquittal of the usual suspect.

This report concerns the case of a 29-year-old male patient suffering from severe psychotic illness who had been satisfactorily treated with clozapine for 4 months. Clozapine had also been successfully administered during a psychotic episode 5 years previously. Though symptoms of psychosis were successfully controlled following the most recent psychotic episode, a medical consultation assessed that exacerbation of pancreatitis warranted discontinuation of the current antipsychotic treatment regime. Following a series of unsuccessful courses of neuroleptic medication, a magnetic resonance cholangiopancreaticography (MRCP) revealed marked cholecystolithiasis suggesting a biliary pancreatitis. Clozapine treatment was readministered following cholecystectomy. After 4 weeks of antipsychotic treatment the patient was discharged from hospital on clozapine monotherapy.

Pain prevalence and risk distribution among inpatients in a German teaching hospital.

OBJECTIVES: This study was designed to provide a cross-sectional analysis of pain prevalence, chronicity, and severity as well as the impact of pain on psychological and social variables in inpatients in various departments of a German teaching hospital. METHODS: Patients were asked to complete a questionnaire including sections on sociodemographic and socioeconomic data, pain variables, recent and past health care utilization, and screening questionnaires for depression, anxiety, and health-related quality of life. RESULTS: Of the 438 patients, 386 (88.1%) had experienced pain in the past 12 months; 367 (83.8%) reported having pain in the previous 3 months. Sixty-four percent of the pain patients stated that pain was the main reason for hospital admission; 48% reported having three or more pain sites. The most common location of pain was the back (26.9%). Pain patients showed significantly higher depression and anxiety scores and markedly reduced physical health when compared to non-pain patients. DISCUSSION: The results of this study indicate that in most medical disciplines pain is more than merely a symptom of disease. In many instances pain should be considered a serious comorbidity that can influence the outcome of medical and surgical treatment. Recent research has shown that prevention of the pain chronification process is the most promising strategy for avoiding the development of intractable pain. Acceptance, recognition, and assessment of pain as a risk factor at an early stage are essential factors. A first step might involve routine screening for pain on admission to any hospital facility, and subsequently evaluating the impact of pain on biopsychosocial functions.

Tiagabine: efficacy and safety in partial seizures - current status.

Tiagabine hydrochloride (TGB) is a selective gamma-aminobutyric acid (GABA) reuptake inhibitor. TGB is effective as an add-on medication in adults and children 12 years and older in the treatment of partial seizures. Results of nonrandomized add-on trials with TGB show treatment success with seizure reduction of at least 50% in 33% to 46% of patients. In newly diagnosed patients with partial epilepsy, TGB monotherapy was as effective as carbamazepine. Comedication with TGB elevates the risk of nonconvulsive status (7.8% vs 2.7% without TGB). The most common side effects include dizziness/lightheadedness, asthenia/lack of energy and somnolence. TGB has no negative effects on cognition; it does not increase the risk of fractures or rash. TGB may interfere with color perception. TGB presents an intermediate risk for depression in patients with epilepsy (approximately 4%). Regarding the risk of overdose, 96-680 mg TGB (mean 224 mg) caused seizures or coma. TGB is an antiepileptic drug exhibiting a specific anticonvulsive mechanism of action, the efficacy of which is relatively low when used in comedication. Critical side effects, such as the induction of nonconvulsive status epilepticus, further limit its use.

Reproductive dysfunction in women with epilepsy: menstrual cycle abnormalities, fertility, and polycystic ovary syndrome.

Epilepsy can be associated with reproductive endocrine disorders. In women these include polycystic ovary syndrome (PCOS), isolated components of this syndrome such as polycystic ovaries or hyperandrogenemia, hypothalamic amenorrhea (HA), or functional hyperprolactinemia (HPRL). The most likely explanations for endocrine disorders related to epilepsy are a direct influence on the endocrine control centers in the brain (the hypothalamic-pituitary axis) or are effects of antiepileptic drugs (AEDs) on peripheral endocrine glands. Furthermore, the effects of AEDs on the metabolism of hormones and binding proteins and secondary endocrine complications of AED-related weight changes or changes of insulin sensitivity must be considered. Therefore, regular monitoring of reproductive function at visits, including questioning about menstrual disorders, fertility, weight, hirsutism and galactorrhea are recommended. Single abnormal laboratory or imaging findings without symptoms may not constitute a clinically relevant endocrine disorder. However, patients with these kinds of abnormalities should be monitored in order to detect the possible development of a symptomatic disorder associated with, for example, menstrual disorders or fertility problems. If a reproductive endocrine disorder is subsequently found, AEDs should be reviewed in terms of their indication for the particular seizure type and their tolerability vis-à-vis their potential for contributing to the endocrine problem.

Prolactin, subjective well-being and sexual dysfunction: an open label observational study comparing quetiapine with risperidone.

INTRODUCTION: Sexual dysfunction is a frequent side effect of antipsychotic treatment. Increased prolactin levels are believed to be responsible for this sexual impairment despite contradictory results. AIM: The primary objective of the present study was to examine the relationship between sexual dysfunction, subjective well-being and prolactin levels in patients with schizophrenia treated either with risperidone or quetiapine. The secondary objective was to explore the relationship between testosterone and the severity of positive and negative symptoms of schizophrenia in male patients. METHODS: In a 4-week nonrandomized open label observational study, 102 inpatients with schizophrenia were recruited. Sexual functioning, subjective well-being and endocrinological parameters were assessed as well as psychopathological characteristics. MAIN OUTCOME MEASURES: Two self-rating questionnaires concerned with sexual functioning ("Essener Fragebogen zur Sexualität") and Subjective Well-Being Under Neuroleptic Treatment Scale (SWN) were completed by the patients. Plasma levels of prolactin in male and female patients were measured. Furthermore, in male patients testosterone, luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were determined. Positive and Negative Symptom Scale (PANSS) was applied. RESULTS: After 4 weeks, patients treated with quetiapine reported less severe sexual impairment, as well as lower PANSS negative and general score compared with patients treated with risperidone. Additionally, emotional regulation as measured with the SWN was higher in patients treated with quetiapine. Risperidone was significantly associated with elevated prolactin levels. Prolactin levels were not correlated either with sexual dysfunction or PANSS. However, in the group of patients treated risperidone, sexual impairment was significantly associated with the SWN subscale emotional regulation. CONCLUSIONS: Increased prolactin levels do not seem to be decisive for antipsychotic induced sexual dysfunction. Improvement of severity of illness and regaining the ability to regulate one's own emotion have positive influence on sexual functioning.

Executive performance of depressed suicide attempters: the role of suicidal ideation.

OBJECTIVE: Suicidal ideation has been related to cognitive rigidity whereas suicidal behaviour itself was associated with specific executive deficits. Yet it remains unclear if a distinct cognitive suicidal phenotype does exist. The aim of the present study was to further investigate the role of suicidal thinking for the neuropsychological performance in depressive suicide attempters. METHOD: Depressive inpatients after a recent suicide attempt, who either had present suicidal ideation (n=14) or not (n=15) and healthy controls (n=29) were recruited. The groups were assessed by means of executive tasks designed to capture impulsive decision-making, and with verbal memory and attention tests. Self-rating measures of impulsivity and aggression were further applied. RESULTS: Only patients with current suicidal ideation showed executive dysfunctions with impaired decision-making being the most salient. Verbal memory and attention were reasonably intact in all patients. All patients reported increased aggression. CONCLUSION: Suicidal ideation is clearly associated with impaired cognitive performance. Our results suggest that executive deficits seen in depressive suicide attempters have a state-dependent component.

Neuropsychological performance in partly remitted unipolar depressive patients: focus on executive functioning.

BACKGROUND: Only few studies have investigated executive impairment in the euthymic phase of unipolar affective disorders, yielding diverging results. The role of impulsivity/orbitofrontal associated executive functioning in remitted depression has not yet been examined. METHODS: Partly remitted male out-patients (n = 15) with non-psychotic major depression (MDD) were compared with healthy males (n = 15) on several neuropsychological tests. Executive tasks focussed on orbitofrontal function (Go/No-Go, Iowa Gambling Task (IGT), delayed alternation task). Furthermore, the Barratt Impulsiveness Scale (BIS-11) was administered to all subjects. RESULTS: Executive skills of the patients were largely unimpaired. Patients exhibited significant deficits on measures of verbal memory only. Residual depressive symptoms in patients were correlated with diminished response inhibition. BIS-11 scores were not elevated in the patients. CONCLUSIONS: Both executive impairment related to orbitofrontal function and self-reported impulsive behaviour in major depression seem to be state-dependent. In accordance with other studies, patients with remitted unipolar depression showed a persistent verbal memory loss.

Remitting form of hemicrania continua: two new cases exhibiting one unusual autonomic feature.

Hemicrania continua (HC) is an uncommon, primary headache disorder characterized by a continuous, strictly unilateral headache of moderate intensity with superimposed exacerbations of more severe pain and accompanying autonomic features. Whereas in the majority of HC patients the headache is continuous and without pain-free intervals, we report two new cases of the rare remitting form of HC. One patient described unusual olfactory sensation during episodes of exacerbation, which we classify as an olfactory aura.

Focal hypertrophic pachymeningitis in association with temporal arteritis.

We present an extremely rare case of a patient with focal hypertrophic pachymeningitis in association with histologically proven temporal arteritis (giant cell arteritis). It is proposed that focal hypertrophic pachymeningitis in itself is the contributing factor to severe headache rather than temporal arteritis alone.