Psychiatric syndromes linked to reproductive function in women: a review of current knowledge

Four psychiatric syndromes related to reproductive function in women have been identified: postpartum depression, premenstrual syndrome (PMS), post-hysterectomy depression, and involutional melancholia. The authors review what is known about these syndromes and conclude, first, that postpartum depression comprises three separate syndromes, the most severe of which is most likely a variant of primary affective disorder. Second, research into the syndromal nature, biology, and treatment of PMS is still in its infancy due to a variety of methodological difficulties. Third, the rate of depression among women during the involutional period or following hysterectomy for benign pathology is not higher than it is at other times.     

Sweets, chocolate, and atypical depressive traits

An original questionnaire, the Foods and Moods Inventory (FMI) was used to investigate appetite for sweets and chocolate and its relationship to dysphoric mood. The FMI was administered to a group of subjects with an identified interest in chocolate (chocolate group, N = 73), a comparison sample (comparison group, N = 172), and a sample of former alcoholics (N = 22). Those who reported "self-medicating" with sweets or chocolate were more likely to have personality traits associated with hysteroid dysphoria, an atypical depressive syndrome. In addition, the tendency to eat compulsively, in general, and appetite for sweets and chocolate, in particular, were significantly greater among women.     

Gabapentin in the acute treatment of refractory bipolar disorder

Background: Gabapentin, a new anti-epileptic agent, has been anecdotally reported to be effective in the treatment of mania. We systematically assessed the response rate in bipolar patients being treated adjunctively with gabapentin for manic symptoms, depressive symptoms, or rapid cycling not responsive to standard treatments.
Method: Twenty-eight bipolar patients experiencing manic (n=18), depressive (n=5), or rapid-cycling (n=5) symptoms inadequately responsive to at least one mood stabilizer were treated in an open fashion with adjunctive gabapentin. Illness response was assessed using the Clinical Global Impression Scale modified for bipolar disorder (CGI-BP). A 'positive response' was operationalized as a CGI response of much or very much improved.
Results: Fourteen of the 18 (78%) treated for hypomania or mania had a positive response to a dosage range of 600–3600 mg/day. Patients with hypomania responded fastest, with a positive response achieved in 12.7±7.2 days. Patients with classic mania had a mean time to positive response of 25±12 days, and in patients with mixed mania it was 31.8±20.9 days. All of the five patients treated for depression had a positive response within 21±13.9 days. Only one of five patients with rapid cycling had a positive response. Gabapentin was well tolerated by all patients, with the most common side-effect being sedation.
Conclusions: Gabapentin appears to have acute anti-manic and anti-depressant properties as an adjunctive agent for refractory bipolar illness. Prospective double-blind studies are needed to further delineate its acute efficacy when used as monotherapy and its prophylactic efficacy as monotherapy or in conjuction with other mood stabilizers.     

Localization of C-reactive protein in synovium of patients with rheumatoid arthritis

Synovial biopsies from 8 patients with rheumatoid arthritis, 2 patients with degenerative osteoarthritis, and 4 patients with nonarthritic disease were studied for localization of C-reactive protein (CRP) using immuno-fluorescence microscopy. The nuclei of many synoviocytes and histiocytes in rheumatoid synovial membrane were found to bind CRP. Cultures of rheumatoid synovium in ¹⁴C-labeled amino acids produced radioactive IgG, IgM, IgA, and C3, but not CRP, indicating the synovial-bound CRP was not of local origin. A few CRP-binding nuclei were present in one osteoarthritic synovium, but none was found in the other and none in synovium from the 4 non-arthritic patients. The nature of the nuclear CRP ligand in rheumatoid synovium was not determined.     

Factors associated with home environmental problems among community-living older people

Purpose : This paper describes the types of difficulties older people have with their home environments and the factors associated with having such difficulties. Method : Data were used from 296 study participants of the University at Buffalo's Consumer Assessments Study that examines the home modification needs and environmental difficulties of older people. A combination of socio-demographic variables, health and functional status indicators and measures of psychosocial well-being were used to predict environmental problems. Results : An average of 13 problems with the environment that posed as a barrier to safe and independent performance was observed in homes. It was found that most difficulties occurred in bathrooms, kitchens, bedrooms and access to entryways and rooms. Hierarchical multiple regression analysis showed that having home environmental problems was most strongly associated with younger age, being female, being of minority status, having pain, and greater physical disability. Conclusion : The findings show that a combination of conditions that include demographic and functional conditions place older people at risk for problems with the home environment that impede performance of daily living activities.     

Predictors of complicated grief among dementia caregivers: a prospective study of bereavement.

OBJECTIVE: Most family caregivers adapt well to the death of their care recipient relative; however, a sizable minority continues to experience postdeath psychiatric morbidity. The purpose of this study was to better understand why some caregivers manifest clinical levels of complicated grief postdeath. This is the first study to prospectively assess predictors of complicated grief among family caregivers of patients with dementia who experience the death of their care recipient. METHOD: The sample of bereaved caregivers is drawn from a larger study of 1,222 family caregivers providing in-home care to their relative with dementia. In-home assessments of caregivers and patients were carried out at baseline and six-month intervals for a total of 18 months. This article is based on the 217 caregivers who experienced the death of their care recipient in the course of the study. Three logistic regression models are tested to identify pre- and postbereavement predictors of complicated grief, including sociodemographic factors, characteristics of the caregiving experience, including participation in a caregiver intervention, other psychiatric morbidities, and medication use. RESULTS: Twenty percent of dementia caregivers evidenced complicated grief along with high levels of depressive symptomatology postdeath. Controlling for sociodemographic factors, caregivers who had high levels of preloss depressive symptoms and burden, reported positive features of the caregiving experience, and were caring for a more cognitively impaired patient were more likely to report clinical levels of complicated grief postloss. In addition, caregivers who were enrolled in a psychosocial caregiver intervention designed to reduce depression and burden reported lower levels of complicated grief. CONCLUSION: This study identifies predictors of complicated grief for which interventions could be developed to not only ease caregiver distress, but also serve as preventive interventions for bereavement. Reducing the burden of active caregiving, treating depression before the death of the loved one and providing supportive psychosocial and skills training caregiver interventions can prevent the emergence of postdeath psychiatric morbidity.     

The role of acute decompression and restoration of spinal alignment in the prevention of post-traumatic syringomyelia: case report and review of recent literature

STUDY DESIGN: Case report. INTRODUCTION: Acute post-traumatic syringomyelia formation after spinal cord injury has been considered a rare complication. At this writing, most recent reports have surfaced in neurosurgical journals. As an entity, post-traumatic syringomyelia has not been widely appreciated. It has been confused with conditions such as Hansen's disease or ulnar nerve compression at the cubital tunnel. One study also demonstrated that the occurrence of syrinx is significantly correlated with spinal stenosis after treatment, and that an inadequate reduction of the spine may lead to the formation of syrinx. This reported case describes a patient in whom post-traumatic syringomyelia began to develop 3 weeks after injury, which improved neurologically after adequate decompression. SUMMARY OF BACKGROUND DATA: A 30-year-old man sustained a 20-foot fall at work. He presented with a complete spinal cord injury below T4 secondary to a T4 fracture dislocation. The patient underwent open reduction and internal fixation of T1-T8. After 3 weeks, the patient was noted to have ascending weakness in his bilateral upper extremities and some clawing of both hands. METHODS: A computed tomography myelogram demonstrated inability of contrast to pass through the T4-T5 region from a lumbar puncture. An incomplete reduction was noted. The canal showed significant stenosis. A magnetic resonance image of the patient's C-spine showed increased signal in the substance of the cord extending into the C1-C2 area. The patient returned to the operating room for T3-T5 decompressive laminectomy and posterolateral decompression including the pedicles, disc, and posterior aspect of the body. Intraoperative ultrasound monitoring showed a good flow of cerebrospinal fluid past the injured segment. RESULTS: On postoperative day 1, the clawing posture of the patient's hands was significantly diminished, and the patient noted an immediate improvement in his hand and arm strength. Over the next few days, the patient's strength in the bilateral upper extremities increased to motor Grade 4/5 on manual testing. A magnetic resonance image 4 weeks after decompression showed significant improvement in the cord diameter and signal. CONCLUSIONS: Post-traumatic syringomyelia has not been reported at so early a stage after injury. This disorder is an important clinical entity that must be recognized to prevent potentially fatal or devastating complications. As evidenced by the reported patient and the literature, if this disorder is discovered and treated early, permanent deficit can be avoided. The prevention of post-traumatic syringomyelia requires anatomic realignment and stabilization of the spine without stenosis, even in the case of complete injuries, to maintain the proper dynamics of cerebrospinal fluid flow.     

Mineralization of the deep gray matter with age: a retrospective review with susceptibility-weighted MR imaging

BACKGROUND AND PURPOSE: Susceptibility-weighted imaging (SWI) is an advanced MR imaging sequence that can be implemented at high resolution. This sequence can be performed on conventional MR imaging scanners and is very sensitive to mineralization. The purpose of this study was to establish the course of mineralization in the deep gray matter with age by using SWI.Materials and METHODS: We retrospectively reviewed susceptibility-weighted images of 134 patients (age range, 1 to 88 years). Inclusion criteria comprised a normal conventional MR imaging (T1, T2, and fluid-attenuated inversion recovery sequences). We statistically analyzed the relative signal intensities of the globus pallidus, putamen, substantia nigra, caudate nucleus, red nucleus, and thalamus for correlation with age. The putamen was graded according to a modified scale, based on previous work that described a systematic pattern of mineralization with age. Bands of hypointensity in the globus pallidus, dubbed “waves,” were also evaluated.RESULTS: We documented decreasing intensity (ie, increasing mineralization) with age in all deep gray matter areas analyzed. We confirmed the age-related posterolateral to anteromedial progression of mineralization in the putamen. Characteristic medial and lateral bands of mineralization were exhibited in the globus pallidus in all children and young adults older than 3 years. Finally, an increase in the number of “waves” present in the globus pallidus was associated with increased age by category.CONCLUSION: This study documents the course and pattern of mineralization in the deep gray matter with age, as determined by SWI. These findings may play a role in evaluating diseased brains in the future.

In 1958, Hallgren and Sourander¹ performed some of the earliest work on characterizing brain iron. They studied iron distribution in various tissues, including the deep gray matter, during an autopsy of brains from 98 subjects, excluding those with cerebrovascular or neuropsychiatric disorders. Iron was found to increase with age in most brain tissues. In the globus pallidus, red nucleus, substantia nigra, and dentate nucleus, iron increases rapidly from birth until the end of the second decade, plateaus for several years, and then shows another milder increase after age 60. Iron increases more slowly in the putamen and caudate, levelling off in the fifth or sixth decade. Subsequent iron-staining studies have largely supported the work of Hallgren and Sourander.¹Most brain iron, other than that found in hemoglobin, is protein-bound, nonheme iron. Approximately one third of nonheme iron is postulated to be in the form of ferritin, though this fraction may be higher in certain deep gray matter structures. Other forms include transferrin, lactoferrin, hemosiderin (thought to be degenerated ferritin), ionic iron, and possibly biogenic magnetite.^2,3 The 2 most important compounds in brain-iron regulation are transferrin, which is used in iron transport, and ferritin, which is used in iron storage. Transferrin and ferritin are also thought to be the only forms of nonheme iron that have a high enough concentration in the brain to be detected currently by MR.³ The mechanisms by which iron and other minerals are deposited in the brain are not well understood. Although the bulk of iron required for the metabolic activity of the adult brain is taken up during the neonatal period, experiments with radioactively labeled iron indicate that small amounts continue to be transported into the adult brain.⁴ In particular, the basal ganglia may exhibit increased susceptibility to mineralization because of their high metabolic rate, and the pattern of mineralization may, in part, relate to the functional vascular components of the striatum.^5,6 Mineral deposits may, in turn, restrict blood flow and cause neural tissue injury that leads to further mineralization.It is believed that the destruction of gray matter causes the release of iron, which is then taken up by activated microglia. Studies have linked increased brain mineralization with several diseases (eg, Parkinson, Alzheimer, Huntington, dementia with Lewy bodies, multiple sclerosis, hemochromatosis, Hallervorden-Spatz, Down syndrome, and AIDS). Histochemical analysis of mineralization of the basal ganglia has shown that many other minerals may be present in addition to iron (eg, calcium, manganese, zinc, copper, magnesium, aluminum, potassium, phosphorus).^5,7 It has been found that the accumulation of iron tends to precede the deposition of calcium and other minerals. These discoveries have underlined the need to develop in vivo imaging techniques sensitive to mineralization, particularly iron.Early attempts at developing such techniques have involved CT imaging.^8,9 More recently, with MR imaging, T2 shortening in the gray matter nuclei with age has been well documented.^10–14 A reduction in T2 is thought to be predominantly related to iron deposition, particularly ferritin,^2,11,15 though 1 team¹⁶ reports contrary findings. The drawback of simply using T2 shortening as a measure of mineralization is that it is also affected by factors such as myelin loss and changes in water concentration, which vary with tissue type, presence of disease, and age.^3,11,13,17 Some researchers have worked on minimizing this effect. Bartzokis et al¹¹ used an imaging process called field-dependent relaxation rate increase (FDRI) to extract that portion of T2 shortening that is the result of mineralization. However, this method is logistically difficult because it requires access to 2 MR machines of different magnetic field strengths as well as careful positioning of the patient in order to extract similar sections from high- and low-field sequences for comparison. Gelman et al¹³ also tried to measure susceptibility using gradient-echo sampling of free induction decay and echo (GESFIDE) MR imaging¹⁸ to measure R2′, ie, that part of the transverse relaxation rate resulting from magnetic field inhomogeneities (R2` = R2* − R2, where R2* refers to the actual observed relaxation rate, and R2 refers to the relaxation rate intrinsic to the tissue). They found a correlation between R2` and iron concentration in the brain. However, they experienced problems with significant magnetic field distortions in the region of the sphenoid sinus and nasal cavity.