Intrathecal morphine in combination with bupivacaine as pre-emptive analgesia in posterior lumbar fusion surgery: a retrospective cohort study.

BACKGROUND: The purpose of this study was to evaluate the efficacy of intrathecal morphine (ITM) in combination with bupivacaine as pre-emptive analgesia in patients undergoing posterior lumbar fusion surgery. This is in comparison with traditional opioid analgesics such as intravenous (IV) morphine. METHODS: Two groups were identified retrospectively. The first (ITM group) included patients who had general anaesthesia (GA) with low-dose spinal anaesthesia prior to induction using 1-4 mls of 0.25% bupivacaine and 0.2 mg ITM. 1 ml of 0.25% bupivacaine was administered per hour of predicted surgery time, up to a maximum of 4 ml. The insertion level for the spinal anaesthetic corresponded to the spinal level of the iliac crest line and the level at which the spinal cord terminated. The control group had GA without any spinal anaesthesia. Patients were instead administered opioid analgesia in the form of IV morphine or diamorphine. The primary outcome was the consumption of opioids administered intraoperatively and in recovery, and over the first 48 h following discharge from the post-anaesthesia care unit (PACU). Total opioid dose was measured, and a morphine equivalent dose was calculated. Secondary outcomes included visual analogue scale (VAS) pain scores in recovery and at day two postoperatively, and the length of stay in hospital. RESULTS: For the ITM group, the median total amount of IV morphine equivalent administered intraoperatively and in recovery, was 0 mg versus 17 mg. The median total amount morphine equivalent, administered over the first 48 h following discharge from PACU was 20 mg versus 80 mg. Both are in comparison with the control group. The median length of stay was over 1 day less and the median VAS for pain in recovery was 6 points lower. No evidence was found for a difference in the worst VAS for pain at day two postoperatively. CONCLUSION: ITM in combination with bupivacaine results in a significantly decreased use of perioperative opioids. In addition, length of hospital stay is reduced and so too is patient perceived pain intensity. Trial registration The study was approved by the ethics committee at The Robert Jones and Agnes Hunt Orthopaedic Hospital as a service improvement project (Approval no. 1617_004).

Extensional rheological data from ex-situ measurements for predicting porous media behaviour of the viscoelastic EOR polymers.

In this article, extensional rheological data of various polymer solutions, to be used in Azad Trivedi viscoelastic model (AT-VEM) for predicting the viscoelastic behavior of synthetic polymer in porous media are provided. Extensional rheology measurements are performed for different polymer solutions using Capillary breakup extensional Rheometer (CaBER) to obtain the filament diameter with respect to time. Extensional rheological parameters, such as the extensional relaxation time, maximum elongational viscosity at the critical Deborah number and strain hardening index are determined from observed filament diameter with time-based on the Upper Convected Maxwell model, the finite extensible non-linear elastic model, and the power law model.

Twelve-month prevalence and treatment gap for common mental disorders: Findings from a large-scale epidemiological survey in India.

BACKGROUND: Common mental disorders, such as mood, anxiety, and substance use disorders, are significant contributors to disability globally, including India. Available research is, however, limited by methodological issues and heterogeneities. AIM: The present paper focuses on the 12-month prevalence and 12-month treatment for anxiety, mood, and substance use disorders in India. MATERIALS AND METHODS: As part of the World Health Organization World Mental Health (WMH) Survey Initiative, in India, the study was conducted at eleven sites. However, the current study focuses on the household sample of 24,371 adults (≥18 years) of eight districts of different states, covering rural and urban areas. Respondents were interviewed face-to-face using the WMH Composite International Diagnostic Interview after translation and country-specific adaptations. Diagnoses were generated as per the International Classification of Diseases, 10th edition, Diagnostic Criteria for Research. RESULTS: Nearly 49.3% of the sample included males. The 12-month prevalence of common mental disorders was 5.52% - anxiety disorders (3.41%), mood disorders (1.44%), and substance use disorders (1.18%). Females had a relatively higher prevalence of anxiety and mood disorders, and lower prevalence of substance use disorders than males. The 12-month treatment for people with common mental disorders was 5.09% (range 1.66%-11.55% for individual disorders). The survey revealed a huge treatment gap of 95%, with only 5 out of 100 individuals with common mental disorders receiving any treatment over the past year. CONCLUSION: The survey provides valuable data to understand the mental health needs and treatment gaps in the Indian population. Despite the 12-month prevalence study being restricted to selected mental disorders, these estimates are likely to be conservative due to under-reporting or inadequate detection due to cultural factors.

Prescription pattern of antidepressants in five tertiary care psychiatric centres of India.

BACKGROUND & OBJECTIVES: Limited data are available on prescription patterns of the antidepressants from India. We studied antidepressants' prescription pattern from five geographically distant tertiary psychiatric care centers of the India. METHOD: In this cross-sectional study, all patients who attended outpatients department or were admitted in the psychiatry wards at Lucknow, Chandigarh, Tiruvalla, Mumbai and Guwahati on a fixed day, who were using or had been prescribed antidepressant medications, were included. The data were collected on a unified research protocol. RESULTS: A total of 312 patients were included. Mean age was 39±14.28 yr and 149 (47.76%) were females, 277 (87.5%) were outpatients. Among the patients receiving antidepressants, 150 (48.1%) were of diagnoses other than depression. Diabetes mellitus 18 (5.78%) was the most common co-morbid medical illness. A total of 194 (62.2%) patients were using selective serotonin reuptake inhibitors (SSRIs) with escitalopram 114 (36.53%) being the most common antidepressant used. Overall, 272 (87.18%) patients were using newer antidepressants. Thirty (9.62%) were prescribed more than one antidepressant; 159 (50.96%) patients were prescribed hypnotic or sedative medications with clonazepam being the most common (n=116; 37.18%). INTERPRETATION & CONCLUSIONS: About half of the patients with diagnoses other than depression were prescribed antidepressants. SSRIs were the most common group and escitalopram was the most common medication used. Concomitant use of two antidepressants was infrequent. Hypnotic and sedatives were frequently prescribed along with antidepressants.

Single-blind, placebo controlled randomised clinical study of chitosan for body weight reduction.

BACKGROUND: Chitosan is a dietary fibre which acts by reducing fat absorption and thus used as a means for controlling weight. Weight loss clinical trial outcomes, however, have contradictory results regarding its efficacy. The primary objective of the present study was to evaluate the efficacy and safety of a chitosan from fungal origin in treatment of excess weight in the absence of dietary restrictions. METHODS: A phase IV, randomised, multicentre, single-blind, placebo-controlled, clinical study was conducted by administering chitosan capsules (500 mg, five/day) and indistinguishable placebo capsules as daily supplements to 96 overweight and obese subjects for 90 days. The study participants were divided in 2:1 ratio to receive either chitosan (n = 64) or placebo (n = 32). Efficacy was assessed by measuring body weight, body composition parameters, anthropometric measurements, HbA1C level and lipid profile at day 45 and day 90. Also, short form-36 quality of life (QoL) questionnaire was assessed to evaluate improvement in life-style and dietary habits were recorded for calorie intake. Safety was assessed by evaluating safety parameters and monitoring adverse events. RESULTS: The mean changes in body weight were -1.78 ± 1.37 kg and -3.10 ± 1.95 kg at day 45 and day 90 respectively in chitosan group which were significantly different (p < 0.0001) as compared to placebo. BMI was decreased by10.91 fold compared to placebo after 90 day administration. In concert with this, there was also reduction in body composition and anthropometric parameters together with improvement in QoL score. Chitosan was also able to reduce HbA1C levels (below 6 %) in subjects who had initial higher values. The mean caloric intake shows that there was no change in dietary habits of subjects in both groups. Lipid levels were unaffected and all adverse events were mild in nature and unrelated to study treatment. CONCLUSION: Chitosan from fungal origin was able to reduce the mean body weight up to 3 kg during the 90 day study period. Together with this, there was also improvement in body composition, anthropometric parameters and HbA1C, reflecting overall benefits for the overweight individuals. Additionally, there was also improvement in QoL score. It was safe and well tolerated by all subjects. TRIAL REGISTRATION: CTRI/2014/08/004901.

Early mobilisation of thoracolumbar burst fractures without neurology: a natural history observation.

AIMS: The authors present the results of a cohort study of 60 adult patients presenting sequentially over a period of 15 years from 1997 to 2012 to our hospital for treatment of thoracic and/or lumbar vertebral burst fractures, but without neurological deficit. METHOD: All patients were treated by early mobilisation within the limits of pain, early bracing for patient confidence and all progress in mobilisation was recorded on video. Initial hospital stay was one week. Subsequent reviews were made on an outpatient basis. RESULTS: The mean duration from admission to final follow-up was three months, and longer follow-up was undertaken telephonically. The mean kyphosis deformity on arrival was 17.4° (5° to 29°); mean kyphosis at final discharge three months later was 19.5° (1° to 28°). Spinal canal encroachment had no influence on successful functional recovery. DISCUSSION: Pain has not been a significant problem for any patient, irrespective of the degree of kyphosis and no patient has a self-perception of clinical deformity. In all, 11 patients took occasional analgesia. All patients returned to their original work level or better. Two patients died 2.5 years after treatment, from unrelated causes. TAKE HOME MESSAGE: The natural history of thoracolumbar burst fractures without neurology would appear to be benign.

Welcome biological breakthroughs, supply psychosocial insights.

Human behaviour, emotions, and cognition are complex to understand and explain. It is even more difficult to understand the basis for abnormal behaviour, disturbed emotions, and impaired cognitions, something mental health professionals are trying for long. In these pursuits, psychiatry has traversed through eras of humours, witchcraft, spirits, psychoanalysis, and gradually deviated from other medical specialities. Now, with recent biological breakthroughs like advances in psychopharmacology, neuroimaging and genetics, increasingly more emphasis is being given to the biological model of psychiatric disorders. These new biological models have given a more scientific appearance to the speciality. It has also revolutionised the management strategies and outcome of many psychiatric disorders. However, this rapid development in biological understanding of psychiatry also leads to a new wave of reductionism. In an attempt to deduce everything in terms of neurons, neurochemicals, and genes, can we neglect psychosocial aspects of mental health? Patients' personality, expectations, motives, family background, sociocultural backgrounds continue to affect mental health no matter how much 'biological' psychiatry gets. Biological and psychosocial approaches are not mutually exclusive but complementary. Integrating them harmoniously is the skill psychiatry demands for comprehensive understanding of mental and behavioural disorders.

Sociodemographic and clinical profile of homeless mentally ill inpatients in a north Indian medical university.

Homeless mentally ill (HMI) persons are a highly vulnerable and socially disadvantaged population, deprived of even the basic minimal human rights. Data on HMI in India is scarce. This retrospective chart review aimed to evaluate socio-demographic, socio-cultural and clinical profile of HMI patients, and to study reasons of homelessness and outcome related variables in these patients. One hundred and forty homeless persons were admitted to the department of psychiatry of a north Indian medical university from February 2005 to July 2011. Of these, one hundred and twenty-seven (90.7%) had psychiatric illness and six had only intellectual disabilities. The majority of HMI persons were illiterate/minimally literate, adult, male, and from low socioeconomic and rural backgrounds. Most of the patients (55.7%) had more than one psychiatric diagnosis. HMI had considerably high rates of co-morbid substance abuse (44.3%), intellectual disabilities (38.6%) and physical problems (75.4%). Most (84.3%) were mentally ill before leaving home and 54.3% left home themselves due to the illness. Most HMI responded to the treatment. After treatment of mental illness, it was possible to reintegrate about 70% of the patients into their families. Families were willing to accept and support them. Untreated/inadequately treated mental illness was the most common reason for homelessness. Easily accessible treatment and rehabilitation facilities at low cost can improve the plight of such patients. Further research in this area is required.

Prescription pattern of mood stabilizers for bipolar disorder at a tertiary health care centre in north India.

BACKGROUND: Mood stabilizers are drugs used to steady/balance the mood, and are also used to manage symptoms of aggression and impulsivity. There is disparity in prescription pattern across the globe. AIM: The aim of this study was to observe prescription pattern of mood stabilizers for the treatment of bipolar disorder with or without psychotic symptoms. MATERIALS AND METHODS: A sample of 100 adult patients was selected to participate in the study. First 5 patients of bipolar disorder with or without psychotic symptoms from twenty out-patient departments of various consultant psychiatrists of Department of Psychiatry (C.S.M. Medical University, Lucknow) were included in the sample. A written informed consent was obtained and survey method was adopted to conduct the study. RESULTS AND CONCLUSION: Lithium was found to be the most frequently prescribed mood stabilizer, sodium valproate ranked second while carbamazepine was least frequently prescribed.

Diagnostic and statistical manual-5: Position paper of the Indian Psychiatric Society.

The development of the Diagnostic and Statistical Manual-5 (DSM-5) has been an exhaustive and elaborate exercise involving the review of DSM-IV categories, identifying new evidence and ideas, field testing, and revising issues in order that it is based on the best available evidence. This report of the Task Force of the Indian Psychiatric Society examines the current draft of the DSM-5 and discusses the implications from an Indian perspective. It highlights the issues related to the use of universal categories applied across diverse cultures. It reiterates the evidence for mental disorders commonly seen in India. It emphasizes the need for caution when clinical categories useful to specialists are employed in the contexts of primary care and in community settings. While the DSM-5 is essentially for the membership of the American Psychiatric Association, its impact will be felt far beyond the boundaries of psychiatry and that of the United States of America. However, its atheoretical approach, despite its pretensions, pushes a purely biomedical agenda to the exclusion of other approaches to mental health and illness. Nevertheless, the DSM-5 should serve a gate-keeping function, which intends to set minimum standards. It is work in progress and will continue to evolve with the generation of new evidence. For the DSM-5 to be relevant and useful across the cultures and countries, it needs to be broad-based and consider social and cultural contexts, issues, and phenomena. The convergence and compatibility with International Classification of Diseases-11 is a worthy goal. While the phenomenal effort of the DSM-5 revision is commendable, psychiatry should continue to strive for a more holistic understanding of mental health, illness, and disease.

The Oswestry Risk Index: an aid in the treatment of metastatic disease of the spine.

The revised Tokuhashi, Tomita and modified Bauer scores are commonly used to make difficult decisions in the management of patients presenting with spinal metastases. A prospective cohort study of 199 consecutive patients presenting with spinal metastases, treated with either surgery and/or radiotherapy, was used to compare the three systems. Cox regression, Nagelkerke's R(2) and Harrell's concordance were used to compare the systems and find their best predictive items. The three systems were equally good in terms of overall prognostic performance. Their most predictive items were used to develop the Oswestry Spinal Risk Index (OSRI), which has a similar concordance, but a larger coefficient of determination than any of these three scores. A bootstrap procedure was used to internally validate this score and determine its prediction optimism. The OSRI is a simple summation of two elements: primary tumour pathology (PTP) and general condition (GC): OSRI = PTP + (2 - GC). This simple score can predict life expectancy accurately in patients presenting with spinal metastases. It will be helpful in making difficult clinical decisions without the delay of extensive investigations.

Assessment of cognition in non-affected full biological siblings of patients with schizophrenia.

BACKGROUND: Schizophrenia is a devastating psychotic illness which is like the most mental disorders, shows complex inheritance; the transmission of the disorder most likely involves several genes and environmental factors. It is difficult to judge whether a particular person without schizophrenia has predisposing factors for the said disease. A few studies have shown the relative sensitivity and reliability of cognitive and psychophysiological markers of brain function as the susceptibility factors for schizophrenia which may aid us to find people with an increased risk of complex disorders like schizophrenia. The present work is an exploration on cognitive impairments in unaffected siblings of patients suffering from schizophrenia with a framework to explore why a mental disorder occurs in some families but not in others. MATERIALS AND METHODS: This is a single point non-invasive study of non-affected full biological siblings of patients with schizophrenia, involving administration of a battery of neuropsychological tests to assess the cognitive function in the sibling group and a control group of volunteers with no history of psychiatric illness. The control group was matched for age, gender, and education. The siblings were also divided on the basis of the type of schizophrenia their siblings (index probands) were suffering from and their results compared with each other. RESULTS: The siblings performed significantly poorly as compared to the controls on Wisconsin card sorting test (WCST), continuous performance test (CPT), and spatial working memory test (SWMT). The comparison between the sibling subgroups based on the type of schizophrenia in the index probands did not reveal any significant difference. CONCLUSION: These findings suggest that there is a global impairment in the cognition of the non-affected siblings of patients of schizophrenia. Cognitive impairment might be one of the factors which will help us to hit upon people who are predisposed to develop schizophrenia in the future.

Cross-national differences in the prevalence and correlates of burden among older family caregivers in the World Health Organization World Mental Health (WMH) Surveys.

BACKGROUND: Current trends in population aging affect both recipients and providers of informal family caregiving, as the pool of family caregivers is shrinking while demand is increasing. Epidemiological research has not yet examined the implications of these trends for burdens experienced by aging family caregivers. Method Cross-sectional community surveys in 20 countries asked 13 892 respondents aged 50+ years about the objective (time, financial) and subjective (distress, embarrassment) burdens they experience in providing care to first-degree relatives with 12 broadly defined serious physical and mental conditions. Differential burden was examined by country income category, kinship status and type of condition. RESULTS: Among the 26.9-42.5% respondents in high-, upper-middle-, and low-/lower-middle-income countries reporting serious relative health conditions, 35.7-42.5% reported burden. Of those, 25.2-29.0% spent time and 13.5-19.4% money, while 24.4-30.6% felt distress and 6.4-21.7% embarrassment. Mean caregiving hours per week in those giving any time were 16.6-23.6 (169.9-205.8 h/week per 100 people aged 50+ years). Burden in low-/lower-middle-income countries was 2- to 3-fold higher than in higher-income countries, with any financial burden averaging 14.3% of median family income in high-, 17.7% in upper-middle-, and 39.8% in low-/lower-middle-income countries. Higher burden was reported by women than men and for conditions of spouses and children than parents or siblings. CONCLUSIONS: Uncompensated family caregiving is an important societal asset that offsets rising formal healthcare costs. However, the substantial burdens experienced by aging caregivers across multiple family health conditions and geographic regions threaten the continued integrity of their caregiving capacity. Initiatives supporting older family caregivers are consequently needed, especially in low-/lower-middle-income countries.

Suicide and antidepressants: what current evidence indicates.

The documented efficacy and long-term benefit of antidepressants in patients with recurrent forms of severe anxiety or depressive disorders support their use in those individuals with these disorders, who experience suicidal thoughts or behavior. In general, it is assumed that antidepressants are beneficial for all symptoms of depression, including suicidality. However, some evidence suggests that Selective Serotonin Reuptake Inhibitors [SSRIs] may cause worsening of suicidal ideas in vulnerable patients. Systematic reviews and pooled analysis of experimental, observational, and epidemiological studies have investigated the use of SSRIs and their association with suicidality. Taking account of the methodological limitations of these studies, the current evidence fails to provide a clear relationship between their use and risk of suicidality in adults. However, in children and adolescents, there appears to be a bit of increased risk of suicidal ideations and attempts, but not of completed suicides. This risk can be anticipated and managed clinically. Clinicians are, therefore, advised to maintain a close follow-up during the initial treatment periods and remain vigilant of this risk. This advisory, however, should not deter clinicians from the use of effective dosages of antidepressants for a sufficient period of time, in every age group of patients, when clinically needed, and if found suitable otherwise.

Destructive discovertebral degenerative disease of the lumbar spine.

The uncommon variant of degenerative hip joint disease, termed rapidly progressive osteoarthritis, and highlighted by severe joint space loss and osteochondral disintegration, is well established. We present a similar unusual subset in the lumbar spine termed destructive discovertebral degenerative disease (DDDD) with radiological features of vertebral malalignment, severe disc resorption, and "bone sand" formation secondary to vertebral fragmentation. Co-existing metabolic bone disease is likely to promote the development of DDDD of the lumbar spine, which presents with back pain and sciatica due to nerve root compression by the "bone sand" in the epidural space. MRI and CT play a complimentary role in making the diagnosis.

Adjunctive mood stabilizer and benzodiazepine use in older Asian patients with schizophrenia, 2001-2009.

OBJECTIVE: This study surveyed the use of adjunctive mood stabilizers (MS) and benzodiazepines (BZD) in older Asian schizophrenia patients and examined their demographic and clinical correlates. METHOD: Information on hospitalized schizophrenia patients aged 55 years or more were extracted from the database of the Research on Asian Psychotropic Prescription Patterns (REAP) study. A total of 1,452 patients from 9 Asian countries and territories was included in the study. The patients' sociodemographic and clinical characteristics and the prescriptions of antipsychotics, MS and BZD were recorded using a standardized protocol and data collection procedure. RESULTS: The frequency of MS prescription was 26.7% in the pooled sample, with 25.5% in 2001, 26.9% in 2004 and 27.7% in 2009. The corresponding figures for BZD were 20.7%, 20.2%, 18.4% and 23.1%, respectively. Multiple logistic regression analysis of the whole sample revealed that patients on MS were younger and more likely to be men and to have extrapyramidal side effects (EPS) and a longer duration of illness. Compared to patients in China, those in Japan were more likely to receive MS, while Korean patents were prescribed less MS. In contrast, there were no significant sociodemographic or clinical correlates of BZD use. Compared to patients in China, their Korean and Singaporean counterparts were more likely to be on BZD. CONCLUSIONS: The use of MS and BZD is not uncommon in older Asian patients with schizophrenia. Given the paucity of empirical data on the efficacy of these agents in individuals with schizophrenia of any age and concerns about added side effects in older patients in particular, the rationale for the prescription of these agents in this population warrants further examination.

Antipsychotic polypharmacy in inpatients with schizophrenia in Asia (2001-2009).

OBJECTIVE: This study aimed to identify trends in the use of antipsychotic polypharmacy (APP) and their demographic and clinical correlates in the treatment of schizophrenia in Asia between 2001 and 2009. METHOD: A total of 6,761 schizophrenia inpatients in 9 Asian countries and territories were examined; 2,399 in 2001, 2,136 in 2004, and 2,226 in 2009. Patients' socio-demographic and clinical characteristics and prescriptions of psychotropic drugs were recorded using a standardized protocol and data collection procedure. RESULTS: The proportion of APP prescription decreased from 46.8 % in 2001, to 38.3 % in 2004, and increased to 43.4 % in 2009, with wide intercountry variations at each survey. Multiple logistic regression analysis of the whole sample revealed that patients on APP were younger, had a higher dose of antipsychotics in chlorpromazine equivalents, and more severe positive and negative symptoms. They were also more likely to receive depot and fi rst-generation antipsychotic drugs. CONCLUSIONS: The frequency of APP prescription varied between countries and territories, suggesting that a host of clinical and socio-cultural factors played a role in determining APP use in Asia. To resolve the discrepancy between treatment recommendation and clinical practice, regular reviews of prescription patterns are needed.

Tardive dyskinesia in the treatment of schizophrenia: the findings of the Research on Asian Psychotropic Prescription Pattern (REAP) survey (2001 - 2009).

OBJECTIVE: The aim of the study was to survey the frequency of tardive dyskinesia (TD) in patients with schizophrenia and its demographic and clinical correlates in selected Asian countries. METHOD: A total of 6,761 hospitalized schizophrenia patients in nine Asian countries and territories were examined from 2001 to 2009. TD was evaluated as "present" or "absent" according to the clinical judgment of experienced psychiatrists. The patients' socio-demographic and clinical characteristics and the prescriptions of psychotropic drugs were recorded using a standardized protocol and data collection procedure. RESULTS: The frequency of TD in the whole sample was 5.0% with wide variations between countries (0 - 14.9%). Multiple logistic regression analysis showed that the following variables were independently associated with TD: study time, study site, older age, male gender, more severe negative and extrapyramidal symptoms and less anticholinergic drugs. CONCLUSIONS: A generally low frequency of TD in Asian schizophrenia patients with inter-ethnic variations was recorded. It is unclear whether the low prevalence of TD compared with Western data is real or the result of it being insufficiently recognized.