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.     

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.     

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.     

Do depressive symptoms predict mortality in older people?

Context: Depressive symptoms are common in older persons, and may predict mortality.

Objectives: To determine: (1) If depressive symptoms predict mortality; (2) If there is a gradient in this effect; and (3) Which depressive factors predict mortality.

Population: In 1991–1992, 1751 community-dwelling older persons, sampled from a population-based registry, were interviewed.

Measures: The Center for Epidemiologic Studies – Depression (CES-D), age, gender, the Modified Mini-Mental State Examination, self-rated health, and functional status.

Outcome measure: Time to death.

Analysis: Those scoring 16+ on the CES-D were considered depressed. To determine if a gradient was present, the CES-D was treated as a continuous variable. Four depressive factors from the CES-D (depressed affect, positive affect, somatic, and interpersonal) were analyzed. Cox regression models were constructed.

Results: The mortality in those with depressive symptoms was higher in those without depressive symptoms (Hazard Ratio of 1.71, p < 0.001, Log rank test). In multivariable models, this association was no longer significant after accounting for self-rated health and functional status. There was a gradient in risk of mortality across the range of the CES-D. Somatic factors, depressed affect, and positive affect were all associated with mortality in bivariate analyses, but not in multivariable models adjusting for functional status. Interpersonal factors were not associated with mortality.

Conclusions: Depressive symptoms predict mortality in older persons.     

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.     

Consumer satisfaction with antipsychotic medication-monitoring appointments: the role of consumer–prescriber communication patterns

Objective: The study was designed to explore patterns of prescriber communication behaviors as they relate to consumer satisfaction among a serious mental illness sample.

Methods: Recordings from 175 antipsychotic medication-monitoring appointments between veterans with psychiatric disorders and their prescribers were coded using the Roter Interaction Analysis System (RIAS) for communication behavioral patterns.

Results: The frequency of prescriber communication behaviors (i.e., facilitation, rapport, procedural, psychosocial, biomedical, and total utterances) did not reliably predict consumer satisfaction. The ratio of prescriber to consumer utterances did predict consumer satisfaction.

Conclusions: Consistent with client-centered care theory, antipsychotic medication consumers were more satisfied with their encounters when their prescriber did not dominate the conversation.

Practice implications: Therefore, one potential recommendation from these findings could be for medication prescribers to spend more of their time listening to, rather than speaking with, their SMI consumers.     

Spinocerebellar ataxia type 3 presenting with writer's cramp without ataxia

Aim of the study: Spinocerebellar ataxia type 3 is the most common cause of autosomal dominant inherited ataxia worldwide.

Material and methods: Clinically, it exhibits wide phenotypic variability. Presentation as isolated dystonia is exceptional.

Results: Here, the case of a woman with writers cramp without ataxia is presented as a paucisymptomatic manifestation of this disease.

Conclusions: This association has not been described to date and extends the clinical variability of the disease.     

The role of glutamate and its receptors in central nervous system in stress-induced hyperalgesia

Purpose: To explore the potential mechanisms of glutamate and its receptors in stress-induced hyperalgesia.

Materials and methods: The stress-induced hyperalgesia, glutamate and its receptors are listed as key items in the pubmed database and the related articles are searched.

Results: Glutamate level is increased under stress and associated with stress-induced hyperalgesia. Moreover, the role of glutamate in stress-induced hyperalgesia depends on its subtypes of its receptors.

Conclusions: Increased glutamate during stress connect with ionotropic glutamate receptors can prompt hyperalgesia, but connect with metabotropic glutamate receptors can inhibit hyperalgesia.     

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.     

A randomized controlled trial comparing self-referral to inpatient treatment and treatment as usual in patients with severe mental disorders

Background: There has been a call for increased patient autonomy and participation in psychiatry. Some Community Mental Health Centres (CMHC) have implemented services called ‘self-referral to inpatient treatment’ (SRIT) for patients with severe mental disorders.

Aims: To investigate whether SRIT could yield better outcomes after 12 months in use of mental health services for people with severe mental disorders than Treatment As Usual (TAU).

Methods: This was a randomized controlled trial at a CMHC in Norway comparing SRIT and TAU in 12 months. Fifty-four patients with severe mental disorders were included. The patients in the SRIT group could admit themselves as inpatients for up to 5 days for each admission with at least a 2 weeks pause between the admittances.

Results: Twenty out of 26 participants (77%) in the SRIT group used the SRIT for a median of 1.5 admissions and 5 inpatient days. With the exception of a somewhat larger number of admissions at the CMHC in the SRIT group, no significant differences were found between the two groups in days as inpatients, admissions, outpatient contacts or coercion. Both groups reduced their inpatients days by 40%.

Conclusions: Both the SRIT and the TAU groups reduced their use of services during the 12 months intervention period. Giving patients with severe mental disorders the possibility to self-refer did not change the use of services.

Clinical implications: Self-referral to inpatient treatment for patients with severe mental disorders might increase patient autonomy, but does not seem to save use of inpatient services.     

‘Mechanical restraint—confounders,risk, alliance score’: testing the clinical validity of a new risk assessment instrument

Background: Unstructured risk assessment, as well as confounders (underlying reasons for the patient’s risk behaviour and alliance), risk behaviour, and parameters of alliance, have been identified as factors that prolong the duration of mechanical restraint among forensic mental health inpatients.

Aim: To clinically validate a new, structured short-term risk assessment instrument called the Mechanical Restraint–Confounders, Risk, Alliance Score (MR-CRAS), with the intended purpose of supporting the clinicians' observation and assessment of the patient’s readiness to be released from mechanical restraint.

Methods: The content and layout of MR-CRAS and its user manual were evaluated using face validation by forensic mental health clinicians, content validation by an expert panel, and pilot testing within two, closed forensic mental health inpatient units.

Results: The three sub-scales (Confounders, Risk, and a parameter of Alliance) showed excellent content validity. The clinical validations also showed that MR-CRAS was perceived and experienced as a comprehensible, relevant, comprehensive, and useable risk assessment instrument.

Conclusions: MR-CRAS contains 18 clinically valid items, and the instrument can be used to support the clinical decision-making regarding the possibility of releasing the patient from mechanical restraint.

Implications: The present three studies have clinically validated a short MR-CRAS scale that is currently being psychometrically tested in a larger study.     

Exercise after Stroke: Patient Adherence and Beliefs after Discharge from Rehabilitation

Background: Most people complete post-stroke rehabilitation within the first 6 months after stroke even though benefits from exercise are believed to persist well beyond 6 months. Physical and Occupational therapists provide home exercise programs (HEP) to instruct patients on exercises to continue after discharge from rehabilitation. Unfortunately, there is little known about HEP adherence rates in adults with stroke.

Objectives: The objectives of this project were to (1) determine the adherence rate with post-rehabilitation HEP and reasons for non-adherence, (2) assess for interactions between HEP adherence and self-report of depression and fatigue, and (3) determine patient beliefs about the benefit of exercise during stroke recovery.

Design: This was a cross-sectional, survey study.

Methods: A survey was developed and distributed during stroke support group meetings to determine adherence rates with post rehabilitation HEP, reasons for non-adherence, and patient beliefs about the benefit of exercise.

Results: Eighty-nine percent of participants reported receiving a HEP and 65.3% of those reported being adherent with at least part of the HEP. Several reasons for non-adherence were identified, including ‘doing different exercises than the ones given by the physical therapist’, as the most frequently given reason. Study participants identified positive roles of exercise in their recovery from stroke.

Conclusion: Patient adherence with HEP after discharge from rehabilitation is less than ideal. Reasons for non-adherence are varied. Rehabilitation therapists need to be able to identify and help patients manage barriers to HEP adherence to promote management of residual deficits.     

Neurological impairments in hypoxic neonates and lactate levels

Introduction: Metabolic acidosis with increasing lactate concentration develops due to the lack of oxygen in the tissues.

Objectives: The effect of lactic acidosis on neurological development in the first year of life.

Materials and Methods: Our study included 50 newborns with perinatal hypoxia requiring oxygen therapy and 50 healthy newborns. pH, pCO2, pO2, base excess (BE) and lactates from arterialized capillary blood were determined in both groups of newborns, in the first and second hours after birth, and neurological development in the first year of life was estimated.

Results: pH, pCO2, pO2, BE and lactates differed significantly between the groups in the first and second hours after birth p < 0.01. Hypotonia was recorded in 20/50 cases and hypertonia was recorded in 10/50 cases in the first year of life.

Conclusion: Lactate concentration may be an indicator of neurological damage in neonates with perinatal hypoxia.     

Assessing family caregiver skill in managing behavioral symptoms of Alzheimer's disease

Objectives: This measurement study operationalized family caregiver skill in managing behavioral symptoms associated with Alzheimer's disease (AD) by testing a Caregiver Assessment of Behavioral Skill-Self-Report (CAB-SR) measure.

Method: A cross-sectional design was used. Caregivers had a family member with possible/probable AD, resided at home with the care recipient and provided the majority of care (N?=?82). The mail-administered assessment included the CAB-SR and other care recipient and caregiver measures.

Results: Preliminary CAB-SR reliability and validity were determined using reliability, factor analytic and correlational procedures.

Conclusion: This measure provides a preliminary assessment of caregiver skill in managing behavioral symptoms of AD and shows promise for use in research and clinical intervention settings.     

Neurobiology of depression: A neurodevelopmental approach

Objectives: The main aims of this paper are to review and evaluate the neurobiology of the depressive syndrome from a neurodevelopmental perspective.

Methods: An English language literature search was performed using PubMed.

Results: Depression is a complex syndrome that involves anatomical and functional changes that have an early origin in brain development. In subjects with genetic risk for depression, early stress factors are able to mediate not only the genetic risk but also gene expression. There is evidence that endocrine and immune interactions have an important impact on monoamine function and that the altered monoamine signalling observed in the depressive syndrome has a neuro-endocrino-immunological origin early in the development.

Conclusions: Neurodevelopment is a key aspect to understand the whole neurobiology of depression.     

Case series of diagnostic shift from bipolar disorder to schizoaffective disorder

Objective: To describe three cases of diagnostic shift from bipolar I disorder (BD) to schizoaffective disorder (SAD).

Methods: BD patients were clinically assessed and followed up in a mood disorder program. A questionnaire was applied to assess clinical and socio-demographic characteristics, and a Structured Clinical Interview (SCID-I) was conducted.

Results: We identified three patients with diagnosis conversion to SAD from 2005 to 2016. The mean time between BD diagnosis and the diagnostic shift to SAD was 9 years.

Conclusions: Psychotic symptoms may become persistent, chronic and unrelated to the presence of mood episodes many years after the beginning of BD. Psychiatrists should be aware of this and reassess the diagnosis during the longitudinal course of BD, especially in those patients who present psychotic symptoms     

A novel ETFDH mutation in an adult patient with late-onset riboflavin-responsive multiple acyl-CoA dehydrogenase deficiency

Aim of the study: To report a novel mutation in the electron transfer flavoprotein dehydrogenase (ETFDH) gene in an adult patient with late-onset riboflavin-responsive multiple acyl-CoA dehydrogenase deficiency.

Materials and methods: The genomic DNAs from a patient whose main clinical presentations are muscles weakness and hypoglycemia was analysed.

Results: The patient was identified to carry compound heterozygous mutations in ETFDH gene. Two missense mutations c.814 G > A and c.389 A > T were found.

Conclusion: This is the first report of c.814G > A mutation in ETFDH in adult patient with MADD.     

Repetitive transcranial magnetic stimulation therapy for post-stroke non-fluent aphasia: A critical review

Objectives: To assess the efficacy of repetitive transcranial magnetic stimulation for post-stroke non-fluent aphasia through a review of current literature.

Methods: Three electronic databases (Medline, Embase & Scopus) were searched for articles. Relevant studies were further evaluated and studies that met inclusion criteria were reviewed.

Results: The literature search yielded 4713 studies. Thirty-five articles were further evaluated to be included. Thirteen met all inclusion criteria and were chosen for review. The studies provide moderate to strong evidence that rTMS may be an effective treatment for non-fluent stroke aphasia.

Conclusion: There are some strong studies evaluating the efficacy of rTMS in non-fluent stroke patients but further research is required to fully establish the usefulness of this treatment. Future directions and limitations are presented.     

Attitudes towards people with depression and schizophrenia among social service workers in Denmark

Background: Mental health-related stigma is a major public health issue, and is an obstacle to the possibility for successful treatment, recovery, and reintegration.

Aim: To examine attitudes towards mental illness among employees in the social services.

Methods: The study design was part of a large randomized trial, and data presented in this study are baseline data from this trial. Respondents completed a baseline questionnaire to assess the respondents’ attitudes.

Results: A significant difference was found between employees’ personal attitudes towards depression and schizophrenia. The same significant difference was found in the employees’ perceived attitudes. Furthermore, a significant difference was found between the employees’ personal and perceived attitudes. A significant difference was found between the respondents wish for social distance towards depression and schizophrenia in all cases, except regarding the willingness to provide a job at one’s own workplace.

Conclusion: Employees in the social services are comparable to the general public concerning attitudes towards mental illness.

Implications: The results indicate that the employees in social services could have great use of gaining more knowledge about mental illness and ways in which to recognize a mental illness, in order to be able to offer the right kind of help and reduce the treatment gap concerning people suffering from mental illness.