A validation study of the Hong Kong version of Montreal Cognitive Assessment (HK-MoCA) in Chinese older adults in Hong Kong.

OBJECTIVE: To validate the Hong Kong version of Montreal Cognitive Assessment (HK-MoCA) in identification of mild cognitive impairment and dementia in Chinese older adults. DESIGN: Cross-sectional study. SETTING: Cognition clinic and memory clinic of a public hospital in Hong Kong. PARTICIPANTS: A total of 272 participants (dementia, n=130; mild cognitive impairment, n=93; normal controls, n=49) aged 60 years or above were assessed using HK-MoCA. The HK-MoCA scores were validated against expert diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed) criteria for dementia and Petersen's criteria for mild cognitive impairment. Statistical analysis was performed using receiver operating characteristic curve and regression analyses. Additionally, comparison was made with the Cantonese version of Mini-Mental State Examination and Global Deterioration Scale. RESULTS: The optimal cutoff score for the HK-MoCA to differentiate cognitive impaired persons (mild cognitive impairment and dementia) from normal controls was 21/22 after adjustment of education level, giving a sensitivity of 0.928, specificity of 0.735, and area under the curve of 0.920. Moreover, the cutoff to detect mild cognitive impairment was 21/22 with a sensitivity of 0.828, specificity of 0.735, and area under the curve of 0.847. Score of the Cantonese version of the Mini-Mental State Examination to detect mild cognitive impairment was 26/27 with a sensitivity of 0.785, specificity of 0.816, and area under the curve of 0.857. At the optimal cutoff of 18/19, HK-MoCA identified dementia from controls with a sensitivity of 0.923, specificity of 0.918, and area under the curve of 0.971. CONCLUSION: The HK-MoCA is a useful cognitive screening instrument for use in Chinese older adults in Hong Kong. A score of less than 22 should prompt further diagnostic assessment. It has comparable sensitivity with the Cantonese version of Mini-Mental State Examination for detection of mild cognitive impairment. It is brief and feasible to conduct in the clinical setting, and can be completed in less than 15 minutes. Thus, HK-MoCA provides an attractive alternative screening instrument to Mini-Mental State Examination which has ceiling effect (ie may fail to detect mild/moderate cognitive impairment in people with high education level or premorbid intelligence) and needs to be purchased due to copyright issues.

A randomized placebo controlled trial of homocysteine lowering to reduce cognitive decline in older demented people.

INTRODUCTION: Whether homocysteine lowering by B vitamins can reduce cognitive decline in Alzheimer disease and vascular dementia patients is unclear. METHODS AND MATERIALS: 140 subjects with mild to moderate Alzheimer disease or vascular dementia were randomly assigned to take 1 mg of methylcobalamin and 5 mg of folic acid, or placebo once daily for 24 months. The primary outcome was Mattis dementia rating scale (MDRS). Secondary outcomes were MDRS domain scores, neuropsychiatric inventory and Cornell scale for depression in dementia. Measurements were performed at baseline and every six months during the study. Fasting plasma tHCY concentrations were measured at baseline and month 18. RESULTS: Trial groups were well matched in baseline characteristics. The average plasma tHCY concentration of subjects was 14.1 ± 3.8 µmol/L. 80% of subjects completed the trial. The supplement group had average plasma tHCY reduced to 9.3 ± 2.7 µmol/L. There was no significant group difference in changes in any of the neuropsychological scores, but among those with elevated plasma tHCY (>13 µmol/L), the decline in MDRS (construction domain) was significantly smaller in the supplement group (median 0 versus 2 points in placebo group, P = 0.003). CONCLUSION: Homocysteine lowering in dementia patients did not significantly reduce global cognitive decline.

Pulmonary artery thrombosis in a patient with severe acute respiratory syndrome.

Severe acute respiratory syndrome (SARS) is an emerging infectious disease with both pulmonary and extra-pulmonary manifestations. Although coagulation abnormalities are common in these patients, clinically overt thromboembolic events are rarely reported. This report describes the first case of pulmonary artery thrombosis in a patient with laboratory confirmed SARS.

Screening of dementia in Chinese elderly adults by the clock drawing test and the time and change test.

OBJECTIVES: To assess the usefulness, relative ease of administration, and patient acceptance of the clock drawing test as well as the time and change test for detecting dementia in Chinese elderly adults. DESIGN: Prospective case-controlled study. SETTING: Memory clinic and geriatric clinic of a district hospital, Hong Kong. PARTICIPANTS: A convenient sample of 85 subjects aged 65 years or older attending the two clinics during the period from September 2002 to June 2003. MAIN OUTCOME MEASURES: The clock drawing test scored according to Lam's method; the time and change test with modification to the making change task; and the Chinese version of the Mini-Mental State Examination. RESULTS: Demented subjects were matched with non-demented ones with respect to age, sex, educational level, and co-morbidity status. The clock drawing test had a comparable sensitivity (89.4%) but a lower specificity (47.1%) when compared with that of the Chinese version of the Mini-Mental State Examination (96.0 and 76.5%, respectively). In contrast, the time and change test had a lower sensitivity (62.7%) but higher specificity (94.1%). Both tests took significantly less time to complete than the Chinese version of the Mini-Mental State Examination. All except four subjects completed the clock drawing test while all subjects accepted the time and change test well. CONCLUSIONS: The Chinese version of the Mini-Mental State Examination is still the best among the three tests despite the longer time to completion. The clock drawing test may be a good alternative to the Mini-Mental State Examination as an effective screening test for dementia when time does not permit. The time and change test, although time-saving, is not suitable to be used alone because of its low sensitivity.

Acute renal failure related to intravenous immunoglobulin infusion in an elderly woman.

Intravenous immunoglobulin infusion induces acute renal failure via a mechanism of osmotic nephrosis. Most reported cases are related to the use of sucrose-based intravenous immunoglobulin. Maltose-based intravenous immunoglobulin is thought to be a safer alternative and have a lower risk of renal toxicity than sucrose-based preparations. Maltase, but not sucrase, is present in the brush border of proximal convoluted renal tubules, where the maltose is metabolised. We report a case of maltose-based intravenous immunoglobulin-induced acute renal failure in an elderly diabetic woman. In this case, the risk factors included advanced age, hypovolaemia, sepsis, diabetes mellitus, and the high infusion rate of the intravenous immunoglobulin. Maltase is readily inhibited by hyperglycaemia; therefore, poor glycaemic control may predispose patients to develop acute renal failure even with the better-tolerated maltose-based intravenous immunoglobulin.

Successful kidney re-transplantation in a patient with previous allograft kidney tuberculosis.

Opportunistic infections, and in particular tuberculosis (TB), carry substantial morbidity and mortality in solid organ transplant recipients. We report a 39-year-old man who underwent a cadaveric renal transplant. Three months postoperatively, he was diagnosed to have tuberculous infection of his graft kidney manifested as fever and renal impairment. The diagnosis was confirmed by renal biopsy, which showed granuloma formation and positive stain for acid-fast bacilli (AFB). His systemic symptoms responded well to a complete course of anti-tuberculous therapy, but his renal function continued to deteriorate. Graft nephrectomy was performed and the patient underwent a second kidney transplant 1 year later. He remained well and asymptomatic thereafter. No signs of recurrence of tuberculous infection were noted up until the present time. This case illustrates that TB remains an important threat to transplant recipients. Although reactivation of dormant TB is the usual mode of infection, acquisition from the donor graft is also possible. The latter may account for the infection in our case, as our patient had a negative tuberculin skin test and normal chest radiograph prior to transplant. The identification of AFB in the kidney graft less than 3 months postoperatively also suggested that causal relationship. While diagnosing TB in post-transplant recipients is difficult and may require renal biopsy, as in our case, treatment on the other hand is no different from the standard protocols. However, no consensus has been reached on the safety of re-transplantation. Also, the need for graft nephrectomy and chemoprophylaxis remains unclear.

Early unplanned readmission of patients with newly diagnosed tuberculosis discharged from acute hospital to ambulatory treatment.

OBJECTIVE: The aim of this study was to examine whether patients with newly diagnosed tuberculosis (TB) discharged to ambulatory treatment are at risk of unplanned readmission through the emergency department within 28 days of discharge, and the risk factors associated with such readmission. METHODOLOGY: A cohort of 134 patients admitted to an acute medical department with TB, who were subsequently discharged to ambulatory treatment of TB, were studied by a retrospective record review for unplanned readmission in 28 days. Potential risk factors associated with the readmission were recorded during hospital stay and follow-up visits, including age, sex, length of stay, substance abuse, need of assistance in the activities of daily living (ADL), comorbidities, non-compliance, drug complications and use of non-standard drug regimen. RESULTS: Up to 20.1% of patients were readmitted. Factors independently associated with early unplanned readmission were need of assistance in ADL, drug complications, the need to use a non-standard drug regimen and more than three non-chest comorbidities. CONCLUSIONS: A significant readmission rate was found in these patients and potential risk factors were identified. Ambulatory treatment for TB may not be appropriate for selected patients. Local guidelines for the management of TB patients at high risk of readmission is needed.

Strongyloidiasis as a possible cause of nephrotic syndrome.

Chronic strongyloidiasis is a mild disease and has never been reported to be associated with nephrotic syndrome. Disseminated strongyloidiasis is known to have high mortality, but it frequently is not diagnosed until autopsy. We report a patient with nephrotic syndrome developing disseminated strongyloidiasis after steroid therapy. The findings in renal biopsy, the time course of the development, and resolution of nephrotic syndrome after thiabendazole treatment suggested a possible causal relationship between chronic strongyloidiasis and nephrotic syndrome. The case also demonstrated the importance of early diagnosis in disseminated strongyloidiasis and the good clinical outcome of early treatment before the development of organ failure.

Treatment of acute methanol intoxication with hemodialysis using an ethanol-enriched, bicarbonate-based dialysate.

A patient poisoned with methanol was successfully hemodialyzed with an ethanol-enriched, bicarbonate-based dialysate. Along with a concomitant intravenous infusion of ethanol, the ethanol-enriched dialytic procedure was able to maintain an intradialytic plasma ethanol level of 80 to 102 mg/dL. The patient recovered without any sequelae of methanol intoxication.

[Serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA 19-9) values in patients with pancreatic cancer or pancreatitis].

For evaluating the diagnostic rate of serum CA19-9 and carcinoembryonic antigen (CEA) in pancreatic malignancies and pancreatitis, 22 patients with pancreatic malignancy, 27 patients with acute pancreatitis and 7 patients with chronic pancreatitis were included in this prospective study. The normal values of CEA and CA19-9 were 2.0 ng/ml and 36 U/ml respectively in 10 healthy males and 11 healthy females. The positive rates of CEA (greater than 2.5 ng/ml) in pancreatic malignancy, acute pancreatitis and chronic pancreatitis were 50%, 47% and 38%, respectively. On the other hand, the positive rates of CA19-9 (greater than 37U/ml) in pancreatic malignancy, acute pancreatitis and chronic pancreatitis were 82%, 26% and 23%, respectively. In diagnosis of pancreatic malignancy, the positive rate of CA19-9 is higher than that of CEA (82% vs 50%), and CA19-9 has a sensitivity significantly higher in differentiating from pancreatitis than CEA. In 7 cases of pancreatic malignancy with metastasis (liver or peritoneum), all had abnormally high serum CA19-9 (greater than 195 U/ml), 6 of 7 had CA19-9 levels over 1000 U/ml. In the view of CEA, 6 of 7 had serum CEA over 5 ng/ml, one patient with peritoneal metastasis had normal CEA level. In this study, we conclude that the diagnostic rate of CA19-9 in pancreatic malignancies is better than that of CEA.

Kinetic characterization and radiation-target sizing of the glucose transporter in cardiac sarcolemmal vesicles.

Stereospecific glucose transport was assayed and characterized in bovine cardiac sarcolemmal vesicles. Sarcolemmal vesicles were incubated with D-[3H]glucose or L-[3H]glucose at 25 degrees C. The reaction was terminated by rapid addition of 4 mM HgCl2 and vesicles were immediately collected on glass fiber filters for quantification of accumulated [3H]glucose. Non-specific diffusion of L-[3H]glucose was never more than 11% of total D-[3H]glucose transport into the vesicles. Stereospecific uptake of D-[3H]glucose reached a maximum level by 20 s. Cytochalasin B (50 microM) inhibited specific transport of D-[3H]glucose to the level of that for non-specific diffusion. The vesicles exhibited saturable transport (Km = 9.3 mM; Vmax = 2.6 nmol/mg per s) and the transporter turnover number was 197 glucose molecules per transporter per s. The molecular sizes of the cytochalasin B binding protein and the D-glucose transport protein in sarcolemmal vesicles were estimated by radiation inactivation. These values were 77 and 101 kDa, respectively, and by the Wilcoxen Rank Sum Test were not significantly different from each other.

A review of clinical trials of lithium in medicine.

Since the approval of lithium use in treatment of acute mania, there have been numerous clinical trials of lithium in medical and psychiatric disorders. This paper gives a brief review of the literature on lithium trials in approximately fourteen medical conditions. These are: hyperthyroidism, metabolizing thyroid cancer, syndrome of inappropriate secretion of antidiuretic hormone, premenstrual tension syndrome, anorexia nervosa, Felty's syndrome, chemotherapy-induced neutropenia, aplastic anemia, seborrheic dermatitis, eczematoid dermatitis, cyclic vomiting, diabetes mellitus and asthma. Most of the case reports cited showed the efficacy of the side effects from lithium salt in the management of the symptoms and signs of these disorders, however, well-designed and controlled studies give negative results. The positive results are reported in the group of disorders having an underlying subdromal affective syndrome such as premenstrual tension syndrome and anorexia nervosa. Other encouraging reports include the effect of lithium to induce leucocytosis in Felty's syndrome and chemotherapy-induced neutropenia.

Neuropsychiatric manifestations of alkali metal deficiency and excess.

The alkali metals from the Group IA of the periodic table (lithium, sodium, potassium, rubidium, cesium and francium) are reviewed. The neuropsychiatric aspects of alkali metal deficiencies and excesses (intoxications) are described. Emphasis was placed on lithium due to its clinical uses. The signs and symptoms of these conditions are characterized by features of an organic brain syndrome with delirium and encephalopathy prevailing. There are no clinically distinctive features that could be reliably used for diagnoses. Sodium and potassium are two essential alkali metals in man. Lithium is used as therapeutic agent in bipolar affective disorders. Rubidium has been investigated for its antidepressant effect in a group of psychiatric disorders. Cesium is under laboratory investigation for its role in carcinogenesis and in depressive illness. Very little is known of francium due to its great instability for experimental study.

A review of clinical trials of lithium in neurology.

Lithium has been put to clinical trials in no less than fifteen neurological disorders. They are Huntington's chorea, tardive dyskinesia, spasmodic torticollis, Tourette's syndrome, L-dopa induced hyperkinesia and the "on-off" phenomenon in parkinsonism, organic brain disorders secondary to brain-injury, drug induced delusional disorders, migraine and cluster headache, periodic hypersomnolence, epilepsy, meniere's disease and periodic hypokalemic paralysis. This paper gives a brief summary of the clinical trials with lithium salts reported in the literature. There are encouraging results on the use of lithium in cluster headaches, cyclic form of migraine and hypomanic mood disorders due to organic brain disorders. The trials with lithium and amitriptyline in tardive dyskinesia needs independent confirmation. The effect of lithium on seizure disorders needs to be addressed too.

A synopsis on metals in medicine and psychiatry.

A total of 40 metals are reviewed and summarized to give a general perspective on the metal's two major effects, relevant to medicine and psychiatry in man. These two effects are metal excess (poisoning) and deficiency. These metals are grouped arbitrarily into six categories; (a) The heavy metals, (b) the essential and questionable essential trace elements, (c) the macrominerals, (d) the alkali metals, (e) elements used as therapeutic agents, and (f) miscellaneous elements. The heavy metals are invariably toxic and could be lethal, and no deficiency state has yet been described in man, although arsenic has been postulated to be essential. The essential trace elements are vital to a number of vital physiological and biochemical functions, and newer essential trace elements are to be identified in the future. The recent findings suggest vanadium excess may aggravate the affective symptoms in bipolar affective disorder; selenium may inhibit certain carcinogenesis such as oesophageal cancer; and silicon may inhibit atheromatous formation in the aorta. There is also some suggestion that certain allergic syndromes may be correlated with very low levels of iron, copper, manganese. The study of elements will undoubtedly expand the understanding of disease processes in medicine and psychiatry.

Evaluation and differential diagnosis of movement disorders: a flow chart approach.

This paper presents a flow-chart approach for evaluation and diagnosis of movement disorders MD. It serves as a simple guideline for physicians to evaluate and diagnose patients with MD. It consists of a master flow chart with a step-by-step process for evaluation, a check list table for recording the abnormal findings, a chart for identifying the underlying medical and neurological diseases grouped under the major types of MD, and a table on the drug-induced MD.

Clinical features of movement disorders.

The descriptive aspects of all types of movement disorders and their related syndromes and terminologies used in the literature are reviewed and described. This comprises the features of (a) movement disorders secondary to neurological diseases affecting the extrapyramidal motor system, such as: athetosis, chorea, dystonia, hemiballismus, myoclonus, tremor, tics and spasm, (b) drug induced movement disorders, such as: akathisia, akinesia, hyperkinesia, dyskinesias, extrapyramidal syndrome, and tardive dyskinesia, and (c) abnormal movements in psychiatric disorders, such as: mannerism, stereotyped behaviour and psychomotor retardation. It is intended to bring about a more comprehensive overview of these movement disorders from a phenomenological perspective, so that clinicians can familiarize with these features for diagnosis. Some general statements are made in regard to some of the characteristics of movement disorders.

Case vignettes of movement disorders.

This paper reports five movement disorders cases to serve as a basis for discussion of the problems encountered in the clinical management of these cases, and the pathophysiological mechanisms involved in these disorders as presented. Case 1 is a description of the subjective experience of a patient with acute orofacial dystonia from promethazine. Case 2 is the use of clonazepam is post-head injury tics. Case 3 is the complication from discontinuation of haloperidol and benztropine mesylate treatment. Case 4 is myoclonus in subacute sclerosing Panencephalitis, and Case 5 is rebound tremor from withdrawal of a beta-adrenergic blocker.