Electroconvulsive therapy for the acute management of severe agitation in dementia (ECT-AD): A modified study protocol.

OBJECTIVE: This study began as a single-blind randomized controlled trial (RCT) to investigate the efficacy and safety of electroconvulsive therapy (ECT) for severe treatment-refractory agitation in advanced dementia. The aims are to assess agitation reduction using the Cohen-Mansfield Agitation Inventory (CMAI), evaluate tolerability and safety outcomes, and explore the long-term stability of agitation reduction and global functioning. Due to challenges encountered during implementation, including recruitment obstacles and operational difficulties, the study design was modified to an open-label format and other protocol amendments were implemented. METHODS: Initially, the RCT randomized participants 1:1 to either ECT plus usual care or simulated ECT plus usual care (S-ECT) groups. As patients were enrolled, data were collected from both ECT and simulated ECT (S-ECT) patients. The study now continues in an open-label study design where all patients receive actual ECT, reducing the targeted sample size from 200 to 50 participants. RESULTS: Study is ongoing and open to enrollment. CONCLUSION: The transition of the ECT-AD study design from an RCT to open-label design exemplifies adaptive research methodologies in response to real-world challenges. Data from both the RCT and open-label phases of the study will provide a unique perspective on the role of ECT in managing severe treatment-refractory agitation in dementia, potentially influencing future clinical practices and research approaches.

A Case Report of Perceptual Disturbances with Incidental Calcifications in the Cerebellum.

BACKGROUND: The cerebellum has extensive connections with motor and nonmotor areas of the nervous system. These nonmotor areas include the cognitive, affective, and perceptual areas of the central nervous system. Extensive literature has emerged cognitive documents and mood disorders in patients with cerebellar dysfunction. Perceptual disturbances consistent with cerebellar connections with perceptual areas have not been as widely documented. Case Presentation. We present the case of a 58-year-old female presenting with new onset isolated auditory hallucinations and incidental findings of cerebellar calcifications. CONCLUSION: In light of this case, we discuss an expanding body of evidence that suggests the likely role of the cerebellum in perceptual functioning.

The Role of the Anterior Cingulate Cortex and Insular Cortex in Suicidal Memory and Intent.

Research on the brain regions involved in suicidal behavior has led to the identification of a number of regions as being implicated in the neurobiology of suicide. Some of the brain regions identified have a clear correlation between the levels of activity and suicidal behavior. For some regions, such as the insular cortex and anterior cingulate cortex (ACC), both hyperactivity and hypoactivity have been correlated with suicidal behavior. More studies are needed to characterize more clearly the activity of the insular cortex and ACC when it comes to suicidal behavior. The case report presented adds to the literature seeking to clarify the correlation between ACC and insular activities and suicidal behavior. Structural damage of the insular region and ACC, thus leading to a decline in their activity level, was found in a patient who had resolution of suicidal intent after hypoxic brain injury. We discuss the significance of our findings for the neurobiology of suicide.

Cannabis, Schizophrenia Risk and Genetics: A Case Report of a Patient With Homozygous Valine Catechol-O-Methyltransferase Polymorphism.

The question of whether cannabis can trigger schizophrenia continues to be a subject of interest. There has been an increasing focus on identifying potential genetic factors that may predispose cannabis users to develop schizophrenia. One such gene identified in many studies codes for a catechol-O-methyltransferase (COMT) enzyme polymorphism. These studies, however, are limited by the inclusion of patients displaying psychotic symptoms during cannabis intoxication and those who continue to display psychotic symptoms after its cessation. The latter is of interest in truly understanding the risk of cannabis triggering schizophrenia and more studies are needed to clarify the potential relationship. We present the case of a 24-year-old female who presented with psychotic symptoms and was diagnosed with schizophrenia after extensive cannabis use. In addition, she had a homozygous valine COMT polymorphism, a genetic variant thought to be associated with a predisposition for schizophrenia in cannabis users. We discuss the significance of our findings in understanding the relationship between cannabis use and the development of schizophrenia in genetically predisposed individuals.

Combined Parietal-Insular-Striatal Cortex Stroke with New-Onset Hallucinations: Supporting the Salience Network Model of Schizophrenia.

Brain imaging studies have identified multiple neuronal networks and circuits in the brain with altered functioning in patients with schizophrenia. These include the hippocampo-cerebello-cortical circuit, the prefrontal-thalamic-cerebellar circuit, functional integration in the bilateral caudate nucleus, and the salience network consisting of the insular cortex, parietal anterior cingulate cortex, and striatum, as well as limbic structures. Attributing psychotic symptoms to any of these networks in schizophrenia is confounded by the disruption of these networks in schizophrenic patients. Such attribution can be done with isolated dysfunction in any of these networks with concurrent psychotic symptoms. We present the case of a patient who presents with new-onset hallucinations and a stroke in brain regions similar to the salience network (insular cortex, parietal cortex, and striatum). The implication of these findings in isolating psychotic symptoms of the salience network is discussed.

A Case of Septum Pellucidum Agenesis in a Patient with Psychotic Symptoms.

Agenesis of the septum pellucidum is a rare congenital defect that has been associated with psychiatric disorders, cognitive deficits, learning disabilities, seizures, and neuropsychiatric disturbances. We present the case of a patient with partial agenesis of the septum pellucidum who exhibits disorganized behavior and paranoid and persecutory delusions. We add to the literature of incidental neuropsychiatric symptoms in patients with partial agenesis of the septum pellucidum which is an area that requires further exploration and study. We discuss the implications of these findings in light of previous literature findings.

The Anterior Globus Pallidus Externus of Basal Ganglia as Primarily a Limbic and Associative Territory.

There have been an increasing number of functions attributed to the basal ganglia, such as cognitive, emotional, and motor functions. As a result, there is a growing interest to localize these functions to different subregions of the basal ganglia. Most research on localization has been conducted on animals. The experiments subdivide the basal ganglia regions into motor, limbic, and associative functioning areas. There are sparse reports on the localization of functions in humans. This paper attempts to provide such localization of function with a focus on the globus pallidus externus of the basal ganglia. We present the case of a young man who had impairment in mixed cognitive, perceptual, and mood disturbances. No significant motor symptoms were noted in the patient. Brain imaging demonstrated dense bilateral calcifications in the basal ganglia, bilaterally localizing to the anterior region of the globus pallidus externus. We discuss our findings in light of recent studies that imply that isolated pathology in the anterior region of the globus pallidus externus may be associated with behavioral, mood, and cognitive disturbance without motor symptoms.

Transcranial Magnetic Stimulation for Positive Symptoms in Schizophrenia: A Systematic Review.

Transcranial magnetic stimulation (TMS) has been proposed as a potential treatment add-on for positive symptoms in schizophrenia. To summarize the current evidence for its efficacy, we reviewed clinical trials from the last 20 years that investigated TMS for positive symptoms. We performed a search on the PubMed database for clinical trials that used TMS for the treatment of positive symptoms published in peer-reviewed journals. We excluded reviews, case reports, and opinion papers. Of the 30 studies included, the majority (n = 25) investigated auditory verbal hallucinations. Twelve studies found evidence for a positive treatment effect of TMS on positive symptoms, while 18 did not find enough evidence to conclude that TMS is effective for positive symptoms. However, the small sample size of the majority of studies is a limiting factor for the reliability of previous findings. In conclusion, evidence for an effect of TMS on positive symptoms was mixed. Since most of the studies were performed in patients with auditory verbal hallucinations, further research of TMS for other positive symptoms including thought disorder and delusions is warranted.

Chronic Atypical Depression as an Early Feature of Pituitary Adenoma: A Case Report and Literature Review.

Pituitary adenomas are often diagnosed as incidental findings on brain imaging. We present the case of a 52-year-old African American female patient with long standing depressed mood prior to the incidental finding of a pituitary adenoma. We explore the possibility of certain mood symptoms prompting an early diagnosis of pituitary adenoma.

On Neuropsychiatric Manifestations of Basal Ganglia Injury: A Report of Three Cases and Literature Review.

The basal ganglia have been considered to primarily play a role in motor processing. A growing body of theoretical and clinical evidence shows that in addition to the motor functions the basal ganglia play a key role in perceptual and visual disturbances. This role may be evident in patients with basal ganglia pathology and subsequent manifestation of symptoms that include cognitive, perceptual, and affective disturbances. We present three cases with basal ganglia pathology that demonstrate affective and psychotic symptoms. Two of the cases presented with late onset psychotic disturbances suggesting likely neurological etiologies. The third case presented with treatment refractory psychosis and symptoms that are rare for a diagnosis of schizophrenia. The role of incidental bilateral basal ganglia calcifications in all the cases is discussed. A review of current literature highlighting various neuropsychiatric manifestations of basal ganglia pathologies in various patients with psychiatric symptoms is presented.

Neuropsychiatric Manifestations of Partial Agenesis of the Corpus Callosum: A Case Report and Literature Review.

Agenesis of the corpus callosum is a rare congenital defect that has been linked to psychiatric disorders, cognitive deficits, learning disabilities, and developmental delays. We present the case of a patient with partial agenesis of the corpus callosum who exhibits depressed mood, transient loss of memory, and history of cognitive, social, and behavioral disturbances that developed during his childhood. Recent and pertinent literature was reviewed and the agenesis of the corpus callosum and its associated neuropsychiatric manifestations are discussed.

The Pathophysiology and Management of Coprophagia: A Report of Two Cases and Literature Review.

Coprophagia is a rare and distressing disorder characterized by symptoms of compulsive consumption of feces. Several attempts have been made in literature to explore the pathophysiology, management, and outcomes of this disorder. However, critical questions remain, related to characterizing effective management, features of associated comorbidities, time to recovery of symptoms, sustainability of recovery, and the determinants of outcomes. Unfortunately, there is a dearth of available literature addressing these questions. We present two cases of patients with coprophagia in seeking to address these questions. Common symptoms of thought content disorder related to coprophagic behavior are noted in both cases. A shorter time to resolution of coprophagia is noted in one of the patients compared to previously reported studies. Recent and pertinent literature was reviewed and the implications for diagnosis and management of coprophagia are discussed.

A Case of Strongyloidiasis: An Immigrant Healthcare Worker Presenting with Fatigue and Weight Loss.

BACKGROUND: Strongyloides stercoralis is an intestinal nematode parasite classified as a soil-transmitted helminth, endemic in tropical and subtropical regions. Strongyloides stercoralis can remain dormant for decades after the initial infection. CASE: We describe a patient who was diagnosed with Strongyloides stercoralis infection three weeks after a left inguinal hernia repair and discuss approaches to prevention, diagnosis, and treatment. CONCLUSIONS: Physicians in the United States often miss opportunities to identify patients with chronic strongyloidiasis. Symptoms may be vague and screening tests have limitations. We review current strategies for diagnosis and treatment of chronic intestinal strongyloidiasis in immigrant patients who have significant travel history to tropical regions and discuss the clinical features and management of the infection.