Cognition and amyloid load in Alzheimer disease imaged with florbetapir F 18(AV-45) positron emission tomography.

OBJECTIVE: To examine the association between regional brain uptake of a novel amyloid positron emission tomography (PET) tracer florbetapir F 18 ([(18)F]-AV-45) and cognitive performance in a pilot study. DESIGN: Cross-sectional comparison of [(18)F]-AV-45 in AD patients versus controls. SETTING: Three specialty memory clinics. PARTICIPANTS: Eleven participants with probable Alzheimer disease (AD) by NINDS/ADRDA criteria and 15 healthy comparison (HC) participants. MEASUREMENTS: Participants underwent PET imaging following a 370 MBq (10 mCi) intravenous administration of [(18)F]-AV-45. Regional/cerebellar standardized uptake value ratios (SUVRs) were calculated. Cognition was assessed using Mini-Mental State Examination, Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog), Wechsler Logical Memory IA (immediate recall) test (LMIA), and verbal category fluency. RESULTS: Greater [(18)F]-AV-45 SUVR was associated with poorer performance on all cognitive tests. In the HC group, occipital, parietal, precuneus, temporal, and cortical average SUVR was associated with greater ADAS-Cog, and greater anterior cingulate SUVR was associated with lower LMIA. Two HC participants had [(18)F]-AV-45 cortical/cerebellar SUVR greater than 1.5, one of whom had deficits in episodic recall and on follow-up met criteria for amnestic mild cognitive impairment. CONCLUSION: [(18)F]-AV-45 SUVR in several brain regions was associated with worse global cognitive performance particularly in HC, suggesting its potential as a marker of preclinical AD.

Bone mineral density in postmenopausal Chinese women treated with calcium fortification in soymilk and cow's milk.

UNLABELLED: Eighteen months of daily consumption of milk containing 250 mg calcium prevented bone mineral density (BMD) loss at the hip and the femoral neck in postmenopausal Chinese women aged 45 to 65. INTRODUCTION: Estrogen-related bone loss in postmenopausal women can be prevented by the consumption of milk with high doses of calcium and soymilk with high doses of isoflavones. However, high doses of calcium and isoflavones may not be necessary to attain a beneficial effect of milk and soymilk on BMD. We hypothesized that BMD will increase in postmenopausal Chinese women who consume daily 250 mg calcium in milk or soymilk. Milk prevented bone loss at the hip and the femoral neck in postmenopausal Chinese women. METHODS: A total of 141 eligible Chinese women without osteoporosis, aged 45-65, and postmenopausal for more than 2 years were randomized into groups receiving for 18 months (A) milk with 250 mg calcium daily, (B) soymilk with 250 mg calcium daily, or (C) neither milk nor soymilk. Dual-energy X-ray absorptiometry measured the BMD of the spine and hip at 0, 6, 12, and 18 months. RESULTS: The BMD in the hip (2.52%) and the femoral neck (2.82%) of the women consuming milk was significantly higher (hip, P = 0.01; femoral neck, P < 0.0000001). The women in the control group experienced a reduction in BMD at all sites; the reduction in BMD was only significant at the hip during 12 months (P = 0.008) and at the femoral neck during 18 months (P = 0.005). CONCLUSIONS: Daily consumption of milk containing 250 mg calcium over 18 months prevents BMD loss at the hip and the femoral neck in postmenopausal Chinese women.

Clomipramine ameliorates adventitious movements and compulsions in prepubertal boys with autistic disorder and severe mental retardation.

In an open, nonblind clinical trial, clomipramine reduced adventitious movements and compulsions in five previously medicated prepubertal boys with autistic disorder and severe mental retardation. Poorly adapted rating scales, interrater variability, subject heterogeneity, different treatment histories, and environmental stresses confounded the assessment of treatment effects.

Clinician safety.

Clinician safety is a serious concern for health care professionals because of the great risk of violence in health care workplaces, especially emergency and mental health departments. Assaults on mental health staff are often encountered from patients who are intoxicated with, or suffering withdrawal symptoms from, substances. Additionally, violence toward mental health professionals is frequently encountered from patients diagnosed with paranoid schizophrenia, personality disorders, learning disabilities, and mental retardation. Incidents of assault are often ignored by victims and administrators. Administrators must implement several measures to prevent clinician assault.

Dyskinesias differentiate autistic disorder from catatonia.

Autistic disorder and catatonia are neuropsychiatric syndromes defined by impairments in social interaction, communication, and restricted, stereotypical motor routines. Assessments of children with these disorders are typically restricted in scope by the patients' limited ability to comprehend directions. The authors performed systematic assessments of dyskinesias on six prepubertal boys with autistic disorder and mental retardation and on one adolescent male with catatonia to determine if this type of information could be routinely obtained. The boys with autistic disorder had more stereotypies and tics, a greater degree of akathisia and hyperactivity, and more compulsions than the adolescent with catatonia. Catatonia was associated with catalepsy and dystonic postures. The authors conclude that the diagnostic accuracy and specificity of neuropsychiatric syndromes may be enhanced by the systematic assessment of the dyskinesias associated with each condition.

Movements in autistic disorder.

Autistic disorder, an extremely disabling syndrome with onset in early childhood, is associated with multiple comorbid conditions. Although autistic disorder is heterogeneous in its manifestations, there is a subgroup of individuals with autistic disorder who display movements that appear to be unique for the disorders. Hand flapping and a variety of movements termed stereotypies may be pathognomonic of autistic disorder. Therefore, identification of a movement disorder characteristic of autistic disorder may imply that the individual has autistic disorder.

Hallucinations.

Hallucinations, sensory perceptions without environmental stimuli, occur as simple experiences of auditory, gustatory, olfactory, tactile, or visual phenomena as well as mixed- or complex experiences of more than one simple phenomenon. The nature of the hallucination assists localization, differential diagnosis, and treatment planning. In particular, the presence of persistent visual hallucinations of persons with Parkinson's disease predicts dementia, rapid deterioration, permanent nursing home placement, and death. Hallucinations in persons with Alzheimer's disease are often associated with serious behavioral problems and predict a rapid cognitive decline. Theories of the etiology of hallucinations include (1) stimulation, e.g., neurochemical, electrical, seizure, and ephaptic, and (2) inhibition, e.g., destruction of normally inhibitory functions, resulting in disinhibition as in the Charles Bonnet and phantom limb syndromes. Functional neuroimaging procedures suggest anatomical associations for hallucinations. While hallucinations may be a symptom of medical, neurologic, and psychiatric disorders, they may also occur in a wide range of human experiences.

Pets and health.

Beneficial and adverse effects of pets for individuals in a wide range of circumstances have been reported. Nevertheless, well-designed unbiased experiments and long-term follow-up studies are needed. Pets appear to be therapeutic for some individuals and deleterious for others. The controversies concerning the effects of pets on health merit objective assessment by unbiased researchers.

Should people with nocturnal leg cramps drink tonic water and bitter lemon?

A literature search from 1993 to 1997 using MEDLINE and key-words beverages, muscle cramp, and quinine was performed. Three beverages containing quinine were examined in grocery stores. Analysis indicate that leg cramps are a common phenomenon associated with many comorbid disorders especially peripheral vascular and neurologic disorders. Thus, evaluation of a patient's complaining of leg cramps appropriately includes vascular, neurologic, and musculoskeletal examinations. Laboratory investigation of the symptom of leg cramps warrants as a minimum, assessment of thyroid function and determination of platelet counts and serum levels of electrolytes, calcium, and magnesium. A few small studies suggest that quinine is effective in decreasing the frequency of nocturnal leg cramps but not their severity or duration. Quinine consumed in commercial beverages has been reported to cause potentially fatal immunologically mediated hypersensitivity reactions. The concentration of quinine in commercial beverages varies greatly. Although commercial beverages containing quinine generally are labeled "Contains quinine," they typically lack both nutritional information about the amount of quinine and warnings of the health risks. It appears that 325 milligrams of quinine taken by mouth at bedtime typically relieves nocturnal leg cramps, but lower starting doses are appropriate for senior citizens and individuals with impaired renal function. In general, quinine in any form should be avoided by pregnant women and people with hepatic failure. Quinine consumed for the treatment of leg cramps should be prescribed and monitored by physicians, and people who consume quinine in commercial beverages must be warned of the health risks.

Differentiating myoclonus from tics.

A Myoclonus Versus Tic Checklist facilitates making this vexing differential diagnosis. Although it appears to be a valuable tool for clinical, educational, and research purposes, psychometric characterization of the Myoclonus Versus Tic Checklist is needed.

Clinical assessment of tics.

Comprehensive clinical evaluation of tics includes (1) assessments to diagnose (a) akathisia, myoclonus, stereotypies, and other dyskinesias and (b) their frequent behavioral concomitants, including attention deficits, compulsions, obsessions, and other psychopathologic manifestations, (2) descriptions of movement parameters from the patients, their parents, teachers, and important others, and (3) precise topographical localization of tics.

Hyperkinesias in a prepubertal boy with autistic disorder treated with haloperidol and valproic acid.

A 7-yr.-old Bangladeshi boy with autistic disorder, unspecified mental retardation, asthma, pica, and generalized tonic seizures, presented for hyperactivity, aggression, and disruptive behaviors. He had a history of an elevated blood lead level. He was being treated with haloperidol and valproic acid. He was assessed in an unstimulated state for the occurrence of adventitious movements. He exhibited hand flapping, jumping, running, and spinning as well as other motor and phonic stereotypes typical of autistic disorder. Although the presence of subjective distress and a sensation of inner restlessness could not be ascertained given his cognitive impairments, the objective picture of constant leg movement and inability to sit still was consistent with akathisia. The hyperkinesias may be due to autistic disorder, multiple comorbid conditions, and medications. Further studies with large populations of medicated and unmedicated children with autistic disorder are needed to characterize further the associated movement disorders which may result from neurological disorders and pharmacological treatments.

Clinical assessment of adventitious movements.

Many procedures with variable validity and reliability have been developed in research settings to evaluate adventitious movements and related phenomena in specific populations, e.g., people with schizophrenia treated with dopamine antagonists, but these only provide global assessments or rate specific movements. A battery for rating individuals with possible movements disorders in a comprehensive way in clinical settings is needed so a protocol to assess briefly and thoroughly potential movement disorders was videotaped for five prepubertal boys with autistic disorder and severe mental retardation in a clinical trial. Utilizing a Movement Assessment Battery, four raters independently scored videotapes of 10-16 movements assessments of each of the five subjects. Experienced raters attained agreement of 59% to 100% on ratings of tardive dyskinesia and 48% to 100% on tics. Hindrances to reliability included poor quality of some tapes, high activity of subjects, and fatigue of raters.

A review of the literature and a preliminary study of family compliance in a developmental disabilities clinic.

To investigate the compliance of family members with the treatment recommended for patients, three child and adolescent psychiatrists assessed the charts of all active outpatients in a developmental disabilities clinic in the psychiatric department of a tertiary care municipal hospital utilizing a Family Compliance Checklist, a survey form for chart review, in October, 1993 (n = 40), and in April, 1994 (n = 41). Almost no clients missed appointments over a 6-mo. period. Only one family refused to permit the use of medication. Three families refused to make appointments. The majority of the patients were Hispanic and almost half were Roman Catholic. We conclude that most families of patients in a developmental disabilities clinic comply with recommended treatment plans including scheduled appointments and prescribed medications.

Dyskinesias subside off all medication in a boy with autistic disorder and severe mental retardation.

A boy with autistic disorder and severe mental retardation developed severe dyskinesias, including objective akathisia (probable) and tics, a month after discontinuation of at least two years of treatment with drugs block dopamine receptors. These dyskinesias greatly subsided during a 17-wk. open-label nonblind clinical trial of clomipramine, and returned transiently when the parents abruptly discontinued clomipramine. However, the dyskinesias gradually subsided during two and a half years of follow-up with the boy being off all medication. A few stereotypies remain. We believe this suggests the hypothesis that movement disorders, such as withdrawal and tardive akathisia and tics, occurring in boys with autistic disorder treated with dopamine receptor-blocking drugs may subside months or years after discontinuation of the agents and that clomipramine may facilitate this process. We also hypothesize that some boys with autistic disorder and mental retardation exhibit fewer movement disorders, fewer psychiatric symptoms, and better over-all functioning after they have received no dopamine receptor-blocking drugs for several months, and this improvement continues years after the medication has ceased.

Clinical assessment of self-injurious behavior.

The Timed Self-injurious Behavior Scale is an observational scale rating the frequency of 16 types of self-injurious behaviors during each 10-sec. interval of a 10-min. observation period. Advantages of the scale are utilization of direct observation and independence from the variable recollection of symptoms by subjects and care givers. 19 videotaped sessions of a subject who exhibited eight types of self-injurious behaviors were rated with the scale independently by three raters. Eighty percent and better agreement was found for the four specific forms of those behaviors exhibited by the subject sufficiently frequently, self biting, head punching, head slapping, and hair removal.

Progressive catatonia.

We present the case of a young man with a diagnosis of a childhood-onset pervasive developmental disorder who developed a progressive neurologic deterioration with persistent catatonia and right hemiparesis. On his initial evaluation approximately three years after the onset of mutism, he manifested right hemiparesis and catalepsy. Two years later, although catalepsy had subsided, motor function had deteriorated so that he could not use his hands to feed or dress himself. Oral-facialbuccal dyskinesia manifested by blepharospasm and grimacing were present constantly during waking hours. Quantitative electroencephalography demonstrated markedly decreased amplitude, a finding associated with catatonia. Left sural nerve biopsy indicated large axon cylinder degeneration. Left deltoid biopsy demonstrated perimysial fibrosis and type II fiber predominance. Although magnetic resonance imaging of the head without contrast was normal, positron emission tomography indicated hypometabolism of the right cerebral and the right cerebellar hemispheres. The patient continues to deteriorate despite a course of 25 electroconvulsive treatments. He continues to manifest criteria for catatonia including motoric immobility, mutism, and peculiarities of voluntary movement such as prominent grimacing. We suspect an inherited neurodegenerative disorder. Since catatonia is a treatable condition frequently associated with medical and neurological diseases, examination for the features of catatonia must be included in the assessment of patients with progressive brain degeneration. This report is an attempt to clarify the traits of a serious variant of progressive brain degeneration.