General practitioners facing dementia: are they fully prepared?

Abstract. We assessed knowledge about Alzheimers disease (AD) in a sample of Italian general practitioners (GPs). We first carried out a propedeutic study to verify the ability of an Italian version of the University of Alabama at Birminghams AD Knowledge Test for Health Professionals to distinguish between 20 AD specialists and 20 non-specialists and to gain reference values. We then administered the test, together with a short questionnaire, to 139 GPs attending an educational programme in November 2000. The cut-off score for discriminating specialists from non-specialists was 9. Among the 95 GPs who performed the AD Knowledge Test (68.3% response rate), 21% had a total score 9. Our findings suggest that particular focus should be given to dementia in continuing medical education (CME) programmes for GPs.     

Evaluation of GPs diagnostic knowledge and treatment practice in detection and treatment of early schizophrenia: a French postal survey in Brittany

Aims

Evaluating French general practitioners (GPs) diagnostic knowledge and practice in the detection and treatment of early schizophrenia as well as needs and preferences with specialist services.

Methods

A postal survey comprising 27 questions was conducted among 2,039 GPs from three counties of Western France. Composite scores were calculated to determine a level of diagnostic knowledge.

Results

A total of 515 GPs (25.3 %) responded to the survey. The mean score to determine a level of knowledge on the most important aspects in detecting early stages of schizophrenia was 5.3 ± 2.50 [median = 6 (range 0–10)]. The mean score to determine the overall knowledge of schizophrenia was 8.1 ± 2.98 [median = 8 (range 1–16)]. The majority of surveyed GPs (76.1 %) would treat early schizophrenia pharmacologically. A majority of GPs (53.9 %) advise an insufficient duration of anti-psychotic treatment for first episode psychosis. The vast majority (90.8 %) were in favour of a specialized outpatient service.

Conclusions

French GPs tend to have a deficit in diagnostic knowledge and practice in detection and treatment of early schizophrenia. It seems important to provide GPs with continuing medical education (CME) on detection and management of early schizophrenia and to set up relevant specialized outpatient services.     

Driving in Parkinson’s disease—a health hazard?

Abstract. Background: The driving safety of Parkinsons disease (PD) patients has lately been questioned after several authors reported road accidents caused by sleep attacks in PD patients on dopaminergic medication. Objectives: To determine 1) whether PD patients in general and those on dopaminergic medication in particular are especially prone to cause severe road accidents and 2) whether there are PD symptoms or dopaminergic side effects with the potential to compromise driving safety. Data source: Relevant articles were identified by electronic search of biomedical databases (1966–2002: MEDLINE, EMBASE, PASCAL, PUBMED), the Cochrane Controlled Trials Register, and reference lists of located articles. Results: Despite frequent occurrence of potentially hazardous dopaminergic side effects (2–57 %) and disabling parkinsonian non-motor and motor disabilities (16–63 %), the two existing studies on accident rates suggest that PD patients are not more prone to cause road accidents than the rest of the population. Five further reports including 1346 patients and focusing on dopaminergically induced sleep attacks provided comparably low accident figures (yearly incidence: 0%–2%). Because of low figures meta-analysis was intended but finally deemed inappropriate as the methodology of included studies varied greatly and was frequently flawed. Conclusion: Further prospective community-based well designed studies on accident risk in PD patients are needed to provide evidence based driving recommendations.     

GSK-3β in cerebrospinal fluid of schizophrenia patients

Summary. Cerebrospinal fluid contains proteins and metabolites of brain origin and was extensively studied in psychiatry in the 1970s with few definitive results. We have recently found 40% reduced protein levels of GSK-3 in schizophrenia in postmortem prefrontal cortex, but our attempt to develop a diagnostic marker using peripheral lymphocyte GSK-3 was not successful. In this study we aimed to find whether the reduction in brain GSK-3 is reflected in CSF of schizophrenia patients. We report a significant reduction in CSF GSK-3 protein levels in six schizophrenia patients compared to seventeen healthy subjects. Our results corroborate other studies in which CSF protein levels reflect the alteration found in these proteins in schizophrenia patients postmortem brain.     

A 10 year retrospective audit of long-term apomorphine use in Parkinson’s disease

Abstract Objectives Apomorphine is a potent dopamine agonist useful in the treatment of Parkinsons disease patients with disabling motor fluctuations and off periods, not responding to oral medication. It can also be of benefit in reducing dyskinesia by providing more constant dopaminergic stimulation and permitting lower levodopa dosage. However, there is a paucity of information on long-term benefits of apomorphine, including no large-scale phase III trial. We have examined our experience of apomorphine over the last 10 years, to assess indications, pattern of use, efficacy, and side effect profile. Methods All patients requiring apomorphine were identified through the Parkinsons disease Nurse Specialists records. An audit form was produced so that the same information was gathered from all case-notes. Results There were 107 patients (61 males and 46 females). Mean age of disease onset was 50.9 years, SD±9.3 (range 29–78). The mean duration of disease at start of apomorphine treatment was 10 years (SD±4.8, range2–29). The most common indications for apomorphine were severe unpredictable off periods (75.7 %), motor fluctuations (18.7 %) and dyskinesia (5.6 %). Most patients (63.6 %) used both intermittent subcutaneous injections and infusion via pump; 25.2% were on intermittent injection, and 11.2 % infusion alone. Mean dose per injection was 3.7mg. Mean infusion dose 69.8mg, running over a mean of 13.5 hours. The mean duration of intermittent apomorphine use was 48.2 months. The mean duration of infusion was 25.1 months. Complications included skin problems in 16 patients, 2 had symptomatic hypotension, 2 worsening confusion, 1 new confusion and 5 new hallucinations (after sometime on apomorphine). Sixteen patients have stopped using apomorphine completely. Thirteen have stopped the pump, but continue on intermittent injections. Conclusion Subcutaneous apomorphine is easy for patients to use, is well tolerated and has a low incidence of side effects, especially confusion.     

Analysis of polyglutamine-coding repeats in the TATA-binding protein in different neurodegenerative diseases

Summary. Trinucleotide repeat (TNR) expansion in the gene for TATA binding protein (TBP) has recently been described as causal for spinocerebellar ataxia type 17. The normal number of repeats has been considered to be 42 or less. An intermediate range with reduced penetrance has been assumed to be 43–47 CAA/CAG repeats. We examined this gene in 30 patients with autosomal-dominant cerebellar ataxia (ADCA), 35 patients with sporadic ataxia, 11 patients with Huntingtons disease (HD), 351 patients with idiopathic Parkinsons disease (PD), 105 patients with Alzheimers disease (AD), and 291 controls with no history of neurodegenerative disease. Three patients (one with sporadic PD and two with AD) carrying more than 42 TNRs in the TBP gene were identified. This reveals that the phenotype associated with CAG/CAA expansion in the TBP gene may be heterogeneous.These authors contributed equally to this work     

General practitioners’ experiences and perceptions of mild moderate depression management and factors influencing effective service delivery in rural Australian communities: a qualitative study

Background

Rural communities in Australia face significant disadvantages relating to geographical isolation and limited access to mental health services. Documenting general practitioners’ (GP) experiences and perception of mental health services in rural Australia may be useful to gain insight into rural GP management of mild to moderate depression.

Aims

To explore GPs’ experience and views on which factors influence access to mental health services for mild to moderate depression.

Method

This qualitative study was conducted in 2014 in the Northern Rivers, NSW, Australia. Data were obtained from semi-structured in-depth face-to-face interviews with ten GPs, and analyses were performed using a general inductive method of thematic analysis.

Results

Most GPs believed that the current services for managing mild-moderate depression were adequate, however they also identified the need for better access and more services that were free for patients. GPs had a positive perception of management of depression in a rural setting, identifying advantages including better doctor-patient relationships, continuity of care and the proximity of services. However, GPs also identified several barriers to access to mental health services in a rural setting, including long waiting-times, inadequate patient rapport with referred professionals, cost of treatment, transportation, geographical location, stigma, and lack of education about available mental health services. As a result, GPs frequently self-managed patients in addition to referring them to other community mental health service providers where possible.

Conclusion

Overall, GPs appeared relatively satisfied with the resources available in their communities but also identified numerous barriers to access and room for improvement. Rural GPs often self-managed patients in addition to referring patients to other mental health services providers. This should be taken into account when designing mental health policies, developing new services or re-designing current services in rural communities.

     

Only physical aspects of quality of life are significantly improved by bilateral subthalamic stimulation in Parkinson’s disease

Background The well known global improvement of quality of life (QoL) after bilateral high frequency chronic deep brain stimulation of the subthalamic nucleus (STN DBS) in Parkinsons disease (PD) is in contrast to behavioral disturbances as observed after surgery. Indeed the impact of DBS on physical versus mental aspects of QoL in PD remains unknown. Objective To assess the influence of bilateral STN DBS on physical versus mental aspects of QoL in Parkinsons disease. Methods The results of 27 patients for the Unified Parkinsons disease Rating Scale (UPDRS), Parkinsons Disease Questionnaire 39 (PDQ39) and Short Form 36 health survey questionnaire (SF36) were compared before surgery and after 12 months of bilateral STN DBS. Results Comparing off–dopa conditions before versus 12 months after surgery, both UPDRS part II and part III significantly improved: 32.6% and 52%, respectively. UPDRS part I scores did not change significantly at 12 months. As for PDQ39, the global score significantly improved after surgery (21.1 %) as did four subscores: mobility (25.6 %), activity of daily living (34.5 %), stigma (40.1 %) and bodily discomfort (30 %). Three PDQ39 subscores, however, showed no significant changes: emotional well–being (10.7 %), social support (3.2%) and cognition (8.5 %) and one item even worsened: communication (–7.7 %). In SF36, only physical items significantly improved. Conclusion Using clinicians based rating scale, bilateral STN DBS showed significant improvement in PD patients at 12 month follow up. However, using patients self–assessment scales, the clinical benefit of STN DBS was more subtle: physical items of QoL significantly improved, whereas mental items such as emotional well–being, social support, cognition and communication showed no improvement. Our results are suggestive of a dissociation of motor and non–motor symptoms control after bilateral STN DBS in PD patients.     

Psychological and social aspects in management of Alzheimer’s patients: an inquiry among caregivers

Abstract. A survey in the cities of Genoa and Savona (Italy) was performed to examine stress levels in caregivers of patients with Alzheimers disease in the context of a project of the Italian Ministry of Health named Cronos. It offered free anticholinesterase inhibitor therapy to patients who addressed dedicated Neurological Units; in this occasion caregivers could be invited to express the main difficulties encountered in managing demented people during an interview conducted by health personnel of the Neurophysiology Service. Caregivers were mainly women, daughters or spouses, with a medium educational level, retired, housekeepers, employees or teachers; they claimed a lowering of economic standard of living of the family owing to extra expenses for assistance. Satisfaction was expressed towards specialists, while support by general practitioners and other sanitary services was usually lacking and money contribution from the government or territorial services was considered inadequate. From the emotional point of view, caregivers claim loss of free time, friendships and hobbies, and feel isolated in the social context; sometimes the patients death is thought of as a solution. A strong need for information and support is clearly emerging and any further interventions should take these requirements into consideration.     

Characteristics of neuronal lipofuscin in the superior temporal gyrus in Alzheimer’s disease do not differ from non-diseased controls: a comparison with disease-related changes in the superior frontal gyrus

Neuronal lipofuscin characteristics in the superior temporal gyrus from 21 patients with Alzheimers disease (AD) and from 18 age-matched non-diseased subjects were compared with previously reported findings from the superior frontal gyrus. A discriminant function analysis of lipofuscin characteristics in the superior temporal gyrus did not provide a significant predictive level for cases whose diagnoses were correctly classified (56.4%, P=0.63). In contrast, AD-related decrease in the number of smaller lipofuscin regions in the neurons of the frontal gyrus was confirmed, and the same analysis of lipofuscin characteristics in this region gave a significant predictive level for membership of the AD group of 86.6% (P<0.001). The findings indicate that changes in neuronal lipofuscin related to AD, which may reflect an increased rate of lipofuscin formation, show differences between neocortical regions. This study provides additional information on the distribution of neuropathological characteristics in AD.     

High frequency stimulation of the subthalamic nucleus is efficacious in <Emphasis Type="Italic">Parkin</Emphasis> disease

Abstract High frequency stimulation (HFS) of the subthalamic nucleus (STN) is an efficacious symptomatic treatment for Parkinsons disease. We have analysed the genetic status of a series of consecutive parkinsonian patients implanted for STN HFS and compared the outcome of five carrying mutations in the parkin gene with that of the non-parkin group. All patients obtained sustained control of PD symptoms and achieved functional improvement; in the parkin group the UPDRS motor score improved by 56.4%, the levodopa equivalent daily dosage was reduced by 75.5%. Postoperative medications were reduced more in parkin than in non-parkin patients. We confirm that the current inclusion criteria for STN HFS do not exclude patients carrying mutations in the parkin gene; their clinical outcome is comparable to that of the non-parkin group.     

Pathological gambling in two patients on dopamine replacement therapy for Parkinson’s disease

Abstract. We describe two cases where increases in dopaminergic therapy were initiated by the patients due to perceived deterioration in symptoms of idiopathic Parkinsons disease. Shortly afterwards, both cases also met clinical criteria for pathological gambling. To date, only 29 cases of pathological gambling in patients with Parkinsons disease have been reported. This pathological gambling disorder is an addiction-like behavior triggered by excessive dopaminergic drugs and does not respond to standard therapy for pathological gambling. It only responds to an adjustment of Parkinsons disease therapy.     

Patients with a first episode of schizophrenia spectrum psychosis and their pathways to psychiatric hospital care in South Germany

Abstract.Background: Several first-episode studies of schizophrenia suggest that many patients experience psychotic symptoms for a long time before receiving appropriate treatment. To reduce the time of untreated psychosis, it is necessary to know the patients pathways to psychiatric care. This study was designed to examine patients help-seeking contacts and the delays on their pathways to psychiatric care in Germany.Method: Sixty-six patients with first episode of schizophrenia spectrum psychosis were assessed by the Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS) and were interviewed about their helpseeking contacts before psychiatric admission.Results: In contrast to other findings of long duration of untreated psychosis (DUP), 53% of our patients were admitted after 8 weeks (median) of untreated positive symptoms, although the mean value of 71 weeks corresponds well with the results of other studies. There were important differences in DUP depending on which kind of statistical parameter (median or mean) was used. In contrast to studies from other countries, only 18% of our patients had their first contact with a general practitioner. However, this was the fastest way to psychiatric admission. No differences were found between patients with short (< 1 year) and long (> 1 year) DUP in the duration of time from the first help-seeking contact up to admission.Conclusion: In Germany, a large number of mental health professionals in private practice or different services of psychosocial contact facilities exist in every region and general practitioners are not so important as a link to psychiatric care, although they seem to be functioning well if it is necessary. Therefore, programs designed to reduce the delay of treatment should focus less on general practitioners than on other health services.     

Factors contributing to frequent use of psychiatric inpatient services by schizophrenia patients

Abstract. Background: Although present findings about frequent users of psychiatric inpatient services vary from study to study, some potentially important predictors of frequent use were extracted. The purpose of this study was to examine the potentially contributory factors of frequent use of psychiatric inpatient services by schizophrenia patients and to test the influence single factors have in an overall model. Methods: A total of 307 schizophrenia patients were interviewed five times with intervals of 6 months. Data were collected about service receipt and health care costs, strength of primary diagnosis and comorbidities, as well as about patients needs for care and satisfaction with care. Patients with three or more psychiatric admissions within a 30-month period were defined as frequent users. Results: According to this criterion, 12% of the study population were frequent users. Compared with ordinary users, these patients accounted for significantly higher costs in hospital- and community-based care. Important predictors for frequent use of psychiatric inpatient services were the number of previous hospitalizations and current scores of psychopathology. In addition, a longitudinal analysis showed the importance of social factors for the use of psychiatric inpatient care. Therefore, a number of the frequent users multiple admissions could also be caused by social problems. Conclusions: The mental health system should, thus, provide well-directed community-based resources, which give frequent users support to solve their social problems.     

Pathological properties of the Parkinson’s disease-associated protein DJ-1 in α-synucleinopathies and tauopathies: relevance for multiple system atrophy and Pick’s disease

Mutations in the PARK7 gene DJ-1 are associated with recessive hereditary Parkinsons disease (PD). Fibrillar inclusions of -synuclein comprise the neuropathological hallmarks of PD and related Lewy body diseases as well as multiple system atrophy (MSA). Moreover, neuronal and glial inclusions containing tau have been observed in -synucleinopathy patients. Using a collection of antibodies against DJ-1, we have performed a comprehensive investigation of DJ-1 in -synucleinopathies and tauopathies. DJ-1 was abundantly expressed in reactive astrocytes of patients with neurodegenerative diseases. Likewise, DJ-1 antiserum immunostained reactive astrocytes that became abundant with disease progression in the brain stem of transgenic mice expressing mutant [A30P]-synuclein. Human Lewy bodies as well as Lewy body-like inclusions in the -synuclein transgenic mice were DJ-1 negative. Neuronal tau inclusions were DJ-1 immunopositive in Picks disease (PiD), corticobasal degeneration (CBD), progressive supranuclear palsy (PSP), and Alzheimers disease. In addition, we found DJ-1-immunopositive glial inclusions in CBD, PSP and MSA. Biochemical extraction experiments revealed the specific presence of insoluble, modified DJ-1 in PiD and MSA. Our results suggest that DJ-1 is up-regulated in reactive astrocytes as well as in neuronal and glial cells with specific -synucleinopathy and tauopathy.     

Habituation of auditory event-related potentials in patients with Behcet’s disease

Abstract Behcets disease is a progressive and/or relapsing-remitting multisystem inflammatory disorder. Involvement of the central nervous system occurs in 10%–29% of cases with Behcets disease. The aim of the present study was to assess the effect of repetitive auditory stimulations on event-related potentials (ERP) in patients with Behcets without neurologic manifestations. The study was performed in 14 patients with Behcets disease and 14 healthy volunteers. ERPs were recorded from Fz, Cz and Pz. The auditory ERPs test was continued until 20 artefact-free rare tones were averaged, which was accepted as one trial block. After six blocks were obtained in a sequential manner, the test was completed. According to the results of the present study, P300 latency changed in different manners over trial blocks in the two groups. P300 latency values showed a progressive increase in the controls; however this was not determined in the Behcets group. Thus, habituation was not observed in the patient group. Because of the lack of habituation related to P300 latency, it may be thought that there is an insidious pathologic process in Behcets disease without neurologic manifestation.     

Cardiac sympathetic denervation precedes neuronal loss in the sympathetic ganglia in Lewy body disease

Decreased cardiac uptake of meta-iodobenzylguanidine (MIBG) on [¹²³I]MIBG myocardial scintigraphy has been reported in Parkinsons disease (PD) and dementia with Lewy bodies (DLB). We hypothesized that cardiac sympathetic denervation might account for the pathomechanism. To elucidate the extent, frequency and pattern of cardiac sympathetic nerve involvement in Lewy body disease and related neurodegenerative disorders, we immunohistochemically examined heart tissues from patients with PD (n=11), DLB (n=7), DLB with Alzheimers disease (DLB/AD; n=4), multiple system atrophy (MSA; n=8), progressive supranuclear palsy (PSP; n=5), pure AD (n=10) and control subjects (n=5) together with sympathetic ganglia from patients with PD (n=5) and control subjects (n=4), using an antibody against tyrosine hydroxylase (TH). TH-immunoreactive nerve fibers in the hearts had almost entirely disappeared in nearly all the patients with PD, DLB and DLB/AD, whereas they were well preserved in all the patients with PSP and pure AD as well as in all except for one patient with MSA. In PD, neurons in the sympathetic ganglia were preserved in all except for one patient. Decreased cardiac uptake of MIBG in Lewy body disease reflects actual cardiac sympathetic denervation, which precedes the neuronal loss in the sympathetic ganglia.     

Physical therapy in Parkinson’s disease: an open long-term rehabilitation trial

Abstract. The aim of this study was to evaluate the effects of prolonged physical therapy on disability in patients with Parkinsons disease. The study was designed as an open long-term trial over 20 weeks. Twenty slightly to moderately affected parkinsonian patients were included (Hoehn & Yahr stages: 1.5–3). A comprehensive rehabilitation program was applied three times a week in all patients. Pharmacological treatment was kept stable. Evaluations were performed at baseline, at the end of treatment and after 3 months. Following physical rehabilitation, there was a significant improvement in UPDRS (ADL and motor sections) scores, Self-assessment Parkinsons disease Disability Scale, Ten-Meter Walk test and Zung scale for depression. At 3-month follow-up clinical improvements were largely maintained. A sustained improvement of motor skills in PD patients can be achieved with a long-term comprehensive rehabilitation program.     

P300 and neuropsychological evaluation in Behçet’s disease with and without neurological manifestations

Abstract. We evaluated cognitive dysfunction in Behçets disease (BD) with and without neurological manifestations by P300 and neuropsychological tests. Thirtyfour BD patients without neurological manifestations, eighteen BD patients with neurological manifestations and 15 controls were studied. P300 potentials and neuropsychological tests were performed. P300 latency values and neuropsychological tests were not significantly different from the normal controls in BD patients without neurological manifestations. In neurologically symptomatic patients attention and memory deficits and delayed P300 potentials were found.