Nerve root anomalies detected intra-operatively technical nuances towards achieving a successful surgical outcome: our experience of three case reports at a tertiary level centre

Objective: Analysis of three case reports of nerve root anomalies detected intra-operatively and its implications.

Design: Data collected during one year prospective non-randomised study using hospital records.

Setting: Single tertiary care centre.

Subjects: 3 patients in one year period.     

Use of patient-controlled psychiatric hospital admissions: mental health professionals’ perspective

Background: In a patient-controlled admission (PCA) programme, the decision about hospital admission is made solely by the patient, with no gatekeeper function allocated to the mental health professionals (MHPs). Current knowledge about how MHPs experience and evaluate PCA is sparse.

Aims: This Danish multi-centre study examined the MHP assessment of the PCA programme in daily clinical practice, and compared PCA evaluations made by MHPs and patients.

Methods: A questionnaire was developed and a survey conducted over the course of a year at all Danish mental health units included in the PCA programme. MHPs made an overall evaluation of the PCA programme. At each unique PCA, both patient and MHP evaluated the specific admission when the patient entered the unit and at discharge.

Results: In total, 546 questionnaires were included in the survey, based on 252 unique MHPs. The MHPs rated the PCA programme positively. The MHPs believed that PCA helped patients receive early help and avoid long admissions. Overall, agreement was poor when comparing patients’ and MHPs’ evaluation of the same PCA.

Conclusion: MHPs (and patients) seem to be in favour of implementing the PCA programme. However, results revealed that MHPs and patients have different views of what caused the patient to admit themselves and why patients were discharged.

Clinical implications: MHPs should be aware that patients might have other reasons for admitting and discharging themselves than what seems most obvious to the MHP.     

Effects of Hesel-coil deep transcranial magnetic stimulation for depression – a systematic review

Background: One third of the depressed patients are not improved by antidepressant drugs and psychological treatments, and there is a need for additional treatments. Repetitive transcranial magnetic stimulation (rTMS) is being developed towards an alternative in treatment-resistant depression. Deep transcranial stimulation (dTMS) with the Hesel-coil (H-coil) is a further development of rTMS aiming to enhance the effect by getting the magnetic pulses to penetrate deeper into the brain.

Aims: This report aims to assess the evidence-base for dTMS for depression. The report also includes an assessment of the ethical and economic aspects involved.

Methods: A systematic review of the effects of H-coil dTMS on depression was conducted and the scientific support was evaluated using GRADE (Grading of Recommendations Assessment, Development and Evaluation).

Results: Only one controlled study was identified. In the sham-controlled randomized study, 212 participants with major depression that had not responded to antidepressant medication were enrolled. A two-point superiority in Hamilton Depression Rating Scale was observed in the dTMS arm vs the sham-arm at 4 weeks, but the difference was not statistically significant. No serious adverse events were reported apart from rare cases of epileptic seizures.

Conclusions: The existing scientific support for H-coil dTMS therapy for depression is insufficient. The clinical implication is that the use of dTMS in depression should be restricted to the framework of clinical trials pending further studies. Fortunately, additional studies are underway and the evidence base should presumably improve over the next several years.     

Resistin as an inflammatory marker in patients with schizophrenia treated with clozapine

Background: Schizophrenia is associated with excess cardiovascular comorbidity and mortality related to lifestyle factors, such as lack of physical activity, poor diet, and smoking. The prevalence of metabolic syndrome is increased among patients with schizophrenia, with the highest rates among patients on clozapine treatment. Smoking, obesity, physical inactivity, airway inflammation and obstruction, and adipose tissue and inflammatory marker activation are related in systemic inflammation. Low-grade inflammation is also associated with schizophrenia. Adipokine resistin is a biomarker involving several acute and chronic inflammatory states. However, the inflammatory role of resistin is so far inconclusive and studies in schizophrenia are scanty.

Aims: The aim of the present study was to explore the role of serum resistin as an inflammatory marker in patients with schizophrenia on clozapine treatment.

Methods: Associations between serum levels of resistin and some other selected cytokines/adipokines (adiponectin, leptin, adipsin, IL-6, IL-1Ra, TNF-α, hs-CRP) and metabolic markers in 190 patients with schizophrenia on clozapine treatment were studied using a cross-sectional study design.

Results: Among male patients especially, smokers had higher levels of resistin than non-smokers, and among smokers resistin levels were associated with IL-1Ra and hs-CRP levels. In the whole patient group levels of resistin associated with levels of IL-1Ra, and among male patients with low HDL-cholesterol.

Conclusions: Resistin is a biomarker of systemic inflammation associated with smoking among patients with schizophrenia on clozapine treatment. Resistin might have a role as a marker of cardiovascular comorbidity.     

Sonographic assessment of optic nerve and ophthalmic vessels in patients with idiopathic intracranial hypertension

Background: Early diagnosis and proper monitoring of intracranial pressure (ICP) in idiopathic intracranial hypertension (IIH) could reduce morbidity.

Objectives: The objective was to explore and monitor reflection of raised ICP in IIH on optic nerve sheath diameter (ONSD), papillary height and ophthalmic vessels hemodynamics, using transorbital sonography (TOS).

Methods: The study included 24 IIH patients and 30 controls. Patients were compared to controls (phase I) then reassessed twice; 1 week and 4 weeks later (phase II). Both groups underwent clinical evaluation and TOS to measure ONSD, papillary elevation, and color Doppler indices of the ophthalmic vessels. Patients underwent lumbar puncture (LP) to measure cerebrospinal fluid (CSF) pressure.

Results: ONSD was significantly higher in patients compared to controls (p < 0.001). The cut-off value was 6.2 mm. Papillary elevation (p = 0.006) and ONSD (p = 0.006) were significantly reduced 4 weeks following LP. Baseline color Doppler indices of the ophthalmic vessels were comparable between both groups and the changes observed during the follow-up visits in the patients were insignificant.

Conclusion: Reflected ICP changes on ONSD and papilla, measured by TOS, could be a valuable noninvasive additional tool to diagnose and monitor IIH patients. IIH insignificantly influences ophthalmic vessels hemodynamics.

Abbreviation BMI: Body mass index. CSF: Cerebrospinal fluid. EDV: End diastolic velocity. ICP: Intracranial pressure. IH:intracranial hypertension. IIH: Idiopathic intracranial hypertension. LP: Lumbar puncture. MI: Mechanical index. MRI: Magnetic resonance imaging. MRV: Magnetic resonance venography. OA: Ophthalmic artery OND: Optic nerve diameter. ONSD: Optic nerve sheath diameter. OV: Ophthalmic vein. PIs: Pulsatility indices. PSV: Peak systolic velocity. ROC: Receiver operator characteristic. TOS: Trans-orbital sonography.     

High neutrophil-lymphocyte ratio in schizophrenia independent of infectious and metabolic parameters

Background: Immunological and inflammatory mechanisms play an important role in schizophrenia. In the literature, there are studies investigating neutrophil-lymphocyte ratio (NLR) association with schizophrenia.

Aims: The purpose of this study was to compare NLR values between patients with schizophrenia and healthy controls. In addition, the study aimed to investigate the relationship between NLR and disease severity and some metabolic/inflammatory parameters.

Methods: Fifty-two patients diagnosed with schzophrenia and 53 healthy controls were included in the study. A socio-demographic information form was filled out by the clinician. Height, body weight, waist and hip circumference and blood pressure values of each patient were measured. Severity of disease was assessed by positive and negative syndrome scale (PANSS) and clinical global impression-severity scale (CGI-S). Complete blood count was performed to both patient and control groups. Fasting blood glucose, insulin, HbA1c, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglyceride, total cholesterol and C-reactive protein (CRP) were measured.

Results: The number of leukocytes, neutrophils, monocytes and NLR values in patients with schizophrenia was significantly higher than in the control group. There was no significant relationship between NLR values and the number of hospitalisation, duration of ilness or disease severity in patients. There was no correlation between other laboratory findings and NLR values.

Conclusion: NLR levels are high in schizophrenia independent of metabolic parameters according to the results. So, it can be considered that inflammatory processes may play a role in the etiology of the disease.     

Possible error in the Danish version of the WHO Quality of Life (WHOQOL-BREF) Questionnaire

Background: The WHOQOL-BREF is widely used to measure quality of life.

Aims: The goal of the present study was to use the questionnaire in a doctoral study.

Methods: We studied all the instructions provided by the WHO.

Results: In the Danish version of the WHOQOL-BREF there is a discrepancy between the negatively phrased question 9 and both the syntax file and the verbal instructions for coding the data provided by the WHO.

Conclusions: This is a notification of possible error interpretations in projects that use the questionnaire. This could be corrected by manual correction in the coding process or by changing the negatively phrased question 9.     

Cervical myelitis presenting as occipital neuralgia

Aim: Occipital neuralgia is a common form of headache that is characterized by paroxysmal severe lancinating pain in the occipital nerve distribution.

Methods: The exact pathophysiology is still not fully understood and occipital neuralgia often develops spontaneously. There are no specific guidelines for evaluation of patients with occipital neuralgia.

Result: Cervical spine, spinal cord and posterior neck muscle lesions can induce occipital neuralgia. Brain and spine imaging may be necessary in some cases, according to the nature of the headache or response to treatment.

Discussion: We report a case of cervical myelitis presenting as occipital neuralgia.     

Internal decompression for spinal stenosis (IDSS) for decompression and use of interlaminar dynamic device (CoflexTM) for stabilization in the surgical management of degenerative lumbar canal stenosis with or without mild segmental instability: our initial results

Introduction: Internal decompression of spinal stenosis (IDSS) and Posterior dynamic stabilization (PDS) form a bridge between decompression laminectomy alone and rigid fusion, by attempting to sustain beneficial effects of decompression and stabilization in an attempt to prevent bad effects of relentless degeneration.

Objective: To evaluate the clinical outcome in operated patient of posterior dynamic stabilization.

Design: Data were collected over 1 year in prospective, nonrandomized follow-up study using outcome scales.

Setting: Single surgeon, tertiary care centre in Mumbai, India.

Described here is the operative technique of posterior dynamic stabilization using CoFlex^TM and clinical outcome of 67 consecutive patients using Visual Analogue Scale and Oswestry Disability Score.     

Use of patient-controlled psychiatric hospital admissions: patients’ perspective

Background: By patient-controlled admission (PCA), psychiatric patients with a PCA contract can initiate a brief admission without a health professional gatekeeper. However, research regarding use of PCA is scarce.

Aims: In this Danish multi-centre study, motives for and satisfaction with PCA were explored.

Methods: During a 1-year period, patients from 11 Danish mental health units evaluated PCA using a questionnaire developed for the purpose.

Results: In total, 190 patients evaluated 462 admissions. The majority had concluded a PCA contract to receive early help. PCA was mostly initiated because of mental health conditions, but also because of social and everyday problems. The purpose was mainly to be at peace and prevent symptom increase. Patients from units with a quarantine period felt more ready for discharge than the others. Patients were in general satisfied with PCA (61.7%), but patients who hoped for improved medication or wished to obtain more care were less satisfied.

Conclusions: Patients can use PCA as a means to receive timely help. Motives for patients seeking help are not limited to mental conditions. Expectations that cannot be met within the organizational structure of the PCA programme are associated with less satisfaction. However, regional differences in structures were associated with satisfaction. Patients who had access to shorter PCAs were more satisfied, and a quarantine period may even help patients become more ready for discharge. A brief admission period does not cause dissatisfaction at discharge and can be used in the clinical setting.