Integrated case-based clinical approach in understanding pathways, complexities, pitfalls and challenges in neurodegenerative disorders.

INTRODUCTION: This paper presents 5 cases of neurodegenerative disorders from our tertiary care rural hospital in south India. The purpose of this paper is to generate an emerging common theme by thematic analysis of clinical data from each of these patients. A theme emerged, we identified that there was a common clinical ground in patients with movement disorders and psychiatric symptoms. From this common theme, these patients eventually went on to develop different courses of illnesses. METHODOLOGY: Clinical analysis of a case series of 5 patients with neurodegenerative disorders attending the Medicine or Psychiatry services of our hospital. CONCLUSION: A clear & consistent association between movement disorders and psychiatric symptoms was found. Although our data is limited, we conclude that movement disorders can be early clinical markers of organic psychopathology. However, we are aware that this association can be confounded by substance abuse, stress, sleep disruption and even therapeutic interventions, and thus these factors were accounted for and yet we conclude that movement disorders can be early clinical indictors of organic psychopathology.

Fatal Suicidal Attempt by Deliberate Ingestion of Nicotine-containing Solution in Childhood-onset Depression Mediated through Internet Suicide Guideline: A Case Report.

Nicotine is one of the most easily accessible, commonly abused drugs worldwide and if taken in overdose can cause serious clinical presentation, including cardiac arrhythmias and neurotoxicity mediated through oxidative stress. Its toxicity though rare can cause sudden deaths by cardiovascular arrest, respiratory muscle paralysis, and/or central respiratory failure. Here, we describe a case of intentional fatal ingestion of nicotine sulfate decoction used as a mean for fatal suicidal attempt by a 15-year-old adolescent male who was suffering from childhood-onset depression since about 3 months. He developed drooling of saliva, syncopal attacks, paroxysmal episodes of hematemesis, abdominal pain, signs and symptoms of hypoxia, nonfatal atrial tachycardia, and encephalopathy after ingestion of heavy dose of nicotine-containing concoction; however, he recovered successfully within 24-48 hours without any significant cardiac, respiratory, or neurological deficits (except short-term verbal memory). Authors discussed the details of management and reasons behind the reversible encephalopathy and molecular mechanism of nicotine toxicity. HOW TO CITE THIS ARTICLE: Kamble A, Khairkar P, Kalantri SP, Babhulkar S. Fatal Suicidal Attempt by Deliberate Ingestion of Nicotine-containing Solution in Childhood-onset Depression Mediated through Internet Suicide Guideline: A Case Report. Indian J Crit Care Med 2020;24(8):719-721.

Traumatic subdural haematoma: integrating case-based clinical judgement with guidelines.

Traumatic brain injury (TBI) is one of the leading causes of mortality and morbidity with a significant loss of functional capacity and a huge socioeconomic burden. Road traffic accidents are the most common (60%) cause followed by falls and violence in India and worldwide. This case discusses the story of a 23-year-old man with severe TBI-subdural haematoma, who presented in a comatose state. The patient was a purported candidate for emergency decompressive surgery as per Brain Trauma Foundation (BTF) guidelines but was managed conservatively. This case questions the plausibility of the BTF guidelines for severe TBI, particularly in rural hospitals in India and how such cases are often managed with clinical judgement based on the review of literature. The patient recovered well with a perfect 8/8 on Glasgow Outcome Scale Extended Score.

Impact of Spectral Severity of Alcoholism on Visual-Evoked Potentials: A Neuropsychiatric Perspective.

BACKGROUND: The deleterious effects of alcohol on the brain are replete in literature. Only a few neurophysiologic measures can pick up the neuronal dysfunctions, one of them being visual-evoked potential (VEP). A very limited amount of data exists on the progression of neural abnormalities related to the spectral severity of alcoholism. AIM OF THE STUDY: To evaluate the impact of spectral severity of alcoholism through VEP and to understand the emergence of any specific pattern or morphometric abnormalities related to alcohol-induced neuropsychiatric presentations. METHODOLOGY: A total of 90 cases were recruited in addition to 180 age- and sex-matched controls using purposive and random sampling. The Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version and Campbell Neuropsychiatric Inventory were used to evaluate alcohol disorders and its neuropsychiatric complications apart from the mandatory consultant-specific clinical evaluations of all the cases. Of 90 cases of alcohol dependence, 15 patients were currently abstinent for >6 months, 15 had alcohol intoxication, 15 had signs of alcohol withdrawal, 15 had physical complications, 15 had psychiatric comorbidity, and 15 had neurological complications such as epilepsy. VEP recordings were taken using an Evoked Potential Recorder (RMS EMG. EP MARK II) where the stimulus configuration consisted of transient pattern-reversal method in which a black and white checkerboard was generated full field. RESULTS: Mean age of cases was 37.71 ± 11.49 years compared to 39.43 ± 10.67 years in controls (range 18-65 years). VEP abnormalities comprising of prolonged latencies (62.5%) with a statistically significant difference (P < 0.001) from the healthy controls was observed in cases of alcohol withdrawal syndrome. Predominant amplitude reduction with normal latency was obtained in 37.5% cases of withdrawal. Severe VEP abnormalities, i.e., both latency delay and amplitude reduction, were found in 75% patients with psychiatric comorbidity, 66.67% patients with neurological complications, i.e., epilepsy, and 33.34% patients with physical complications. An explicit finding of prominent interocular differences was a prominent feature present in 25% of patients with complications.

Potential Bedside Utility of the Clock-Drawing Test in Evaluating Rapid Therapeutic Response in the Natural Course of Schizophrenia: A Preliminary Study.

The Clock-Drawing Test (CDT) is a brief, relatively time-efficient, easy to administer at bedside, and well-proven cognitive screening test that assesses a broad range of cognitive abilities in stroke, delirium, and dementia. However, challenges of comprehensive therapeutic outcome evaluations in schizophrenia can also be potentially overcome using CDT. The authors aimed to measure the therapeutic outcome using CDT in 101 schizophrenia patients, irrespective of their diagnostic subtypes. A repeated measures analysis of variance found that improvements on CDT and the Positive and Negative Syndrome Scale were closely correlated, reflecting critical information about therapeutic response measures in schizophrenia.

Atypical waveform morphology in schizophrenia-visual evoked potential as a promising endophenotype.

BACKGROUND: Electrophysiological research has provided measures of dysfunction of visual pathway in schizophrenia through the use of visual evoked potential (VEP) as the neurophysiologic tool. OBJECTIVE: The main objective of this study is to examine the morphology and topography of VEP responses in schizophrenic patients and to explore the potentiality of VEP as an endophenotype. MATERIALS AND METHODS: The study included 20 patients of schizophrenia who were recruited from the outpatient and inpatient department of psychiatry of a tertiary care rural hospital. The patients were assessed by tools such as Positive and Negative Symptoms Assessment Scale and Clinical Global Impression Scale for Severity. Transient Pattern Reversal VEP recordings were taken using an Evoked Potential Recorder (RMS EMG EP MARK II), and it was a cross-sectional study. RESULTS: The mean age of patients was 45.95 ± 10.14 years in the range of 35-60 years. Qualitative analysis of VEP waveforms in people with schizophrenia was performed. Abnormal waveform morphology was observed in 14/20 (70%) of the study population and all of them were the chronic and severe cases. Six out of 15 (40%) showed lack of differentiation of the evoked complex so that the three waves (negative-positive-negative [NPN] complex) could not be identified. In 5 of 15 (33.33%) VEP records, a distinct altered waveform with extinguished second negative component of NPN complex was obtained. CONCLUSION: Qualitative morphometric findings of this study in terms of pattern-reversal VEP waveform abnormalities emerged as a tool to provide evidence of relationship for emerging as first potential biomarker for diagnosing schizophrenia.

Prolonged Apnea During Modified Electroconvulsive Therapy in a Patient of Suicidal Attempt by Organophosphorus Poisoning: A Case Report.

Organophosphorus (OP) pesticides are commonly used in agricultural fields to control pests in India. However, exposure to it can cause poisoning in humans and animals, or it can be taken intentionally as poison to commit suicide. We present a case of a 35-year-old suicidal man who developed prolonged apnea for almost 4 hours on day 13 of OP poisoning after brief general anesthesia induced by propofol and 1 mg/kg of suxamethonium, during the first session of the third cycle of modified electroconvulsive therapy, despite all due precautions. Such prolonged apnea secondary to complex interactions has been reported very rarely in literature. This case therefore, highlights the importance of careful evaluation and monitoring while giving anesthesia to OP-poisoning patients.

Indian Psychiatric Society multicentric study on assessment of health-care needs of patients with severe mental illnesses as perceived by their family caregivers and health-care providers.

AIM: To study the health-care needs of the patients with severe mental disorders as perceived by their family caregivers and the treating psychiatrists. MATERIALS AND METHODS: Caregivers of patients with severe mental disorders and their treating psychiatrists were assessed using Camberwell Assessment of Need-Research Version (CAN-R) scale and indigenously designed Supplementary Assessment of Needs Scale (SNAS). RESULTS: The study included 1494 patients recruited from 15 centers. The mean needs as per the CAN-R, perceived by the caregivers were 7.8 and treating psychiatrists were 8.1. About one-third of needs were unmet. On SNAS, both caregivers and treating psychiatrists reported a mean of 7.9 needs, of which more than half were unmet as per the caregivers. As per the treating psychiatrists, 45.5% of the needs as assessed on SNAS were unmet. There was a high level of correlation between needs perceived by the patients, caregivers and the treating psychiatrists. On CAN-R, main domains of needs as reported by the caregivers were those of money, relief of psychological distress, information about the illness and treatment, welfare benefits, transport, company and food. As per the treating psychiatrists, the most common total needs identified were those of relief of psychological distress, welfare benefits, information about the illness and treatment, money, transport, company self-care and physical health. The most common domains of needs as assessed on SNAS as per the caregivers were those of free treatment, medical reimbursement, psychoeducation, financial help, social support, insurance, more time from the clinicians and travel concession. The treating psychiatrists identified dealing with caregiver's stress as the most common need. CONCLUSIONS: According to the family caregivers and treating psychiatrists, about one-third of the needs of the patients as assessed using CAN-R and about half of the needs as assessed using SNAS are unmet.

Dynamics of electroencephalogram (EEG) in different stages of chronic kidney disease.

AIM: To study Electroencephalogram (EEG) in different stages of chronic kidney disease (CKD). MATERIALS AND METHODS: This observational study was carried out in the Department of Medicine, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha conducted over a period of 24 months, spanning from August 2011 to August 2013. Eighty three cases of CKD at different stages were studied. EEG was done in all the subjects and the various EEG dynamics like morphometric waveform patterns, symmetricity, amplitude were recorded and compared with the different stages of CKD. RESULTS: We found that characteristic changes were observed with increasing severity of CKD. Slow delta wave patterns were more prominent in stage 5 (p<0.0001), asymmetric discharges, dysthymia, sharp wave transients and low amplitude wave forms were more prominent beyond Stage 4 (p<0.0001). CONCLUSION: EEG can be used as an effective tool for detection of subclinical or latent uremic encephalopathy. EEG findings which are characteristics of uremic encephalopathy can be present in CKD patients without overt signs of encephalopathy. So, EEG can be used as a prognostic indicator of response to clinical therapy of CKD.

Indian Psychiatric Society multicentric study on assessment of health-care needs of patients with severe mental illnesses.

AIM: To assess the health-care needs of the patients with severe mental disorders. MATERIALS AND METHODS: Patients with the diagnosis of a severe mental disorder (schizophrenia and related psychotic disorders, bipolar disorder, recurrent depressive disorder, major depressive disorder and obsessive compulsive disorder) were assessed using Camberwell Assessment of Need-Research version (CAN-R) Scale and indigenously designed Supplementary Needs Assessment Scale (SNAS). RESULTS: The study included 1494 patients recruited from 15 centers. The most common diagnostic group was that of affective disorders (55.3%), followed by psychotic disorders (37.6%). The mean number of total needs as perceived by the patients was 7.6 on the CAN-R. About two-third of the needs as assessed on CAN-R were met, and one-third were unmet. On CAN-R, main domains of needs as reported by patients were those of money, welfare benefits, transport, information about the illness and treatment, relief of psychological distress, company, household skills and intimate relationships. On SNAS, the mean number of total needs as perceived by the patients was 7.6 of which 4.1 were met needs. The most common domains of needs as assessed on SNAS were those of financial help, medical reimbursement, psychoeducation, free treatment, certification of mental illness, flexible work/job timings, addressing the caregiver stress and legal aid. CONCLUSION: About two-third of the needs, of the patients with severe mental disorders are met as assessed using CAN-R. However, higher percentages of unmet needs are identified on SNAS. In view of the commonly reported needs, a change in the orientation of services offered to people with mental disorders is very much called for. At the government level, desired policies must be formulated to support the patients with mental disorders.

Genital self-mutilation in a suicide attempt: a rare sequela of a hypochondriacal delusion of infection with HIV.

Genital self-mutilation is mostly seen among psychotic, affective and gender identity disorder(s). We present here a rare case report of such genital self-mutilation in a person with a hypochondriacal delusion of infection with HIV precipitated by erroneous and anxiety-provoking miscommunication during HIV testing. Such cases remind us of the need for systematic and appropriate pre-test and post-test HIV counseling, to help prevent such outcomes.

A 5-year hospital prevalence of child and adolescent psychiatric disorders from central India.

OBJECTIVE: To examine the 5-year hospital prevalence of child and adolescent mental disorders from Central India. METHODS: Using systemic random sampling method, of the 4410 families screened, 4278 children (607 aged 0 to 3 y and 3671 between 4 to 16 y) attending outpatient services of department of pediatrics at the tertiary rural hospital from June 2006 through December 2010 were evaluated. Standardized appropriate psychometric tools were used for both groups. Diagnostic interviews were administered and DSM-IV diagnoses were determined by consensus between two psychiatrists. A comprehensive hospital registration system provided the denominator. RESULTS: Of the 4410 families screened, 4278 (97 %) of the subjects completed interviews. The overall prevalence of psychiatric disorders was found to be 20.8 %. Most common psychiatric disorders in group A were mental retardation (5.6 %) followed by epilepsy (2 %) whereas in group B, depressive disorder (3.73 %) were followed by non-organic enuresis (2.18 %) and ADHD (1.7 %). Eighty one percent of the parents from group A and 83 % of parents from group B of the children affected with psychiatric disorders and neurobehavioral problems had reported that they have had never thought of taking psychiatric consultation for their children. CONCLUSIONS: The results of the study have helped in bridging and supporting the propositions in child epidemiology in India and also have implications for clinical training and practice.

Zotepine-induced convulsive seizures in a chronic case of treatment resistant paranoid schizophrenia.

Adverse effects to antipsychotics are varied, frequently intolerable, often serious and sometimes fatal in clinical practice. Seizures are one of these adverse effects. Almost all first and second generation antipsychotics elicit dose-dependent lowering of seizure threshold, indicating increased seizure risk at higher drug dosages. The adverse event of zotepine induced seizure is published in few case reports. We report the occurrence of myoclonic seizure progressing to generalized tonic-clonic seizures with zotepine along with clear temporal association of dose dependent modulation evident in this case.

Prevalence of oral mucosal disorders in institutionalized and non-institutionalized psychiatric patients: a study from AVBR Hospital in central India.

Dental treatment is reported to be the greatest unattended health need of people with a disability. The aim of the present study was therefore to quantify the prevalence of oral diseases with a psychosomatic component (recurrent aphthous stomatitis, burning mouth syndrome, and oral lichen planus) in psychiatric patients and to screen these patients for any other oral disorders, so that better care could be provided. In this cross-sectional, single-assessment study, 150 psychiatric patients were evaluated for presence of oral disorders. They were screened based on their socio-demographic profiles, clinical profile, and standardized psychiatric scales. The prevalence of recurrent aphthous stomatitis (RAS), burning mouth syndrome (BMS), and oral lichen planus (OLP) was 19.33%(29 patients), 20.66% (31 patients) and 5.33% (8 patients), respectively, amongst all psychiatric patients. The prevalence of burning mouth syndrome was much higher in patients taking psychiatric medications (25%) than in drug-naïve patients. On screening for other oral disorders, 35.33% of psychiatric patients had at least one other such disorder. We concluded that this patient group experiences a considerable burden of occult oral disorders necessitating thorough oral care. We also described the possible causes of the higher prevalence of oral disorders in psychiatric patients.

Growing up with the families of ß-thalassaemia major using an accelerated longitudinal design.

BACKGROUND & OBJECTIVES: It is difficult for a single investigator to study the psychosocial changes that occur over the life span of an individual affected with a chronic illness like ß-thalassaemia major. Therefore, a developmental epidemiological perspective is required to understand the chain of events and problems of psychological nature. We aimed to construct the picture of developmental epidemiology for psychosocial aspects in families of ß-thalassaemia major patients attending a tertiary care hospital in north India. METHODS: The accelerated longitudinal design was used. The sample consisted of 100 children with ß-thalassaemia and their 150 parents, both groups were subdivided further so that each group represented the continuum of longitudinal course. The sampling was done for a period of 16 months from January 2004 to April 2005. RESULTS: Overall 54 per cent of children had significant psychopathology. Within the parents groups, 10 per cent had adjustment disorder, 33.3 per cent depressive disorder, and 10 per cent had anxiety disorder and 11 per cent somatoform disorder; 95 per cent of the parents of newly diagnosed children expressed feeling of dazed and shock, fear of death, hopelessness, separation anxiety and problems with their memory and concentration. There was significant difference only in the domain of psychological health in all the three groups of parents with respect to the quality of life. Among children, quality of life improved with their progression of illness. Growing up with ß-thalassaemic family was analyzed. INTERPRETATION & CONCLUSIONS: The developmental epidemiological perspective was constructed in ß -thalassaemic children and their family using an accelerated longitudinal design. Such a design can test the hypothesized aetiological or developmental function of a targeted risk factor within a developmental path and may be used in studying the psychological impact of even other chronic illnesses over the life span of an individual for conceptual and holistic understanding.

Possible cross-sensitivity between sertraline and paroxetine in a panic disorder patient.

Cross-sensitivity due to paroxetine and sertraline, the SSRIs, is rarely reported in the literature. We report an adverse drug reaction to paroxetine and sertraline in a patient of panic disorder, who initially developed a maculopapular, erythematous, pruritic rash in the third week with sertraline 50 mg/day. The rash resolved within 2 days of its discontinuation and oral supplementation of diphenhydramine and betamethasone. 10 days following discontinuation of sertraline, the patient was shifted on sustain release paroxetine 12.5 mg/day when another skin reaction with the same appearance and distribution appeared on day 4 of it, suggesting a possibility of cross-sensitivity, a drug class effect. This case report intends to improve the awareness among clinicians to use caution when choosing an alternative SSRIs.