Central serotonin 1A receptor binding in temporal lobe epilepsy: a [carbonyl-(11)C]WAY-100635 PET study.

We performed positron emission tomography using [carbonyl-(11)C]WAY-100635, a serotonin 1A (5-HT(1A)) receptor antagonist, in 13 patients with temporal lobe epilepsy (TLE) and in 13 controls. 5-HT(1A) receptor distribution mapping allowed correct lateralization of the epileptogenic temporal lobe in all patients. 5-HT(1A) receptor binding potential (BP(ND)) was significantly reduced in almost all temporal regions of the epileptogenic lobe. Compared with controls, the patients had significantly decreased BP(ND) values in the hippocampus, parahippocampal gyrus, and amygdala. The asymmetry index (AI), which characterizes the interhemispheric asymmetry in BP(ND), was significantly higher in patients than in controls in most regions. Depression scores were not significantly correlated with BP(ND) or AI values. Our data provide further evidence of functional changes in the serotonergic system in TLE. Molecular imaging of the 5-HT(1A) receptor may help to define the in vivo neurochemistry of TLE, and may provide a valuable tool in the noninvasive presurgical assessment of patients with medically refractory TLE.

[Dementia and pain]. / Demenz und Schmerz.

Dementia has been associated with disturbed pain processing and an impaired ability to provide self-reported ratings on pain. Patients with cognitive impairment have been shown to receive pain treatment less frequently than cognitively unimpaired individuals. Comorbidity is common in patients with dementia and a major factor contributing to pain. This demonstrates that a structured evaluation and categorisation of pain is mandatory for the treatment of older patients and that care should be taken to note indirect signs of pain. The appropriate scales are available and we propagate their application. Multimodal pain therapy is superior to one-dimensional approaches. A discussion of the effects and interactions of the analgesics presently available for geriatric care forms an integral part of this review.

Benzodiazepine use in the elderly: an indicator for inappropriately treated geriatric depression?

OBJECTIVE: To measure the prevalence of benzodiazepine (BZD) use and to explore associated demographic and clinical variables of BZD use within a cohort of 75-year- old inhabitants of an urban district of Vienna. METHODS: This is a prospective, interdisciplinary cohort study on aging. Our investigation is based on the first consecutive 500 subjects that completed the study protocol. Demographic and clinical characteristics, benzodiazepine and antidepressant use were documented using a standardized questionnaire. Affective status was assessed using the Hamilton Depression Rating Scale (HAMD), the Geriatric Depression Scale (GDS), and the Spielberger State-and Trait Anxiety Inventory subscales (STAI). RESULTS: Prevalence of BZD use was 13.8%. Compared to non-users, BZD users had significantly higher mean scores at the HAMD (p = 0.001), the GDS (p = 0.026), and the Spielberger State-and Trait Anxiety Inventory subscales (p = 0.003; p = 0.001). Depression was found in 12.0% (HAMD) and 17.8% when using a self-rating instrument (GDS). Less than one-third of depressed subjects were receiving antidepressants. Statistically equal numbers were using benzodiazepines. CONCLUSIONS: Inappropriate prescription of BZD is frequent in old age, probably indicating untreated depression in many cases. The implications of maltreated geriatric depression and the risks associated with benzodiazepine use highlight the medical and socioeconomic consequences of inappropriate BZD prescription.

Psychological reactions in women undergoing fetal magnetic resonance imaging.

OBJECTIVE: To investigate women's psychological reactions when undergoing fetal magnetic resonance imaging (MRI), and to estimate whether certain groups, based on clinical and sociodemographic variables, differ in their subjective experiences with fetal MRI and in their anxiety levels related to the scanning procedure. METHODS: This study is a prospective cohort investigation of 62 women before and immediately after fetal MRI. Anxiety levels and subjective experiences were measured by questionnaires. Groups based on clinical and sociodemographic variables were compared with regard to anxiety levels and to the scores on the Prescan and Postscan Imaging Distress Questionnaire. RESULTS: Anxiety scores before fetal MRI were 8.8 points higher than those of the female, nonclinical, norm population (P<.001). The severity of the referral diagnosis showed a linearly increasing effect on anxiety level before MRI (weighted linear term: F1,59=5.325, P=.025). Magnetic resonance imaging was experienced as unpleasant by 33.9% (95% confidence interval [CI] 21.2-46.6%) and as hardly bearable by 4.8% (95% CI 0-17.5%) of the women. Physical restraint (49.9%, 95% CI 37.4-62.4%), noise level (53.2%, 95% CI 40.7-65.7%), anxiety for the infant (53.2%, 95% CI 40.7-65.7%), and the duration of the examination (51.6%, 95% CI 39.1-64.1%) were major distressing factors. CONCLUSION: Women who undergo fetal magnetic resonance imaging experience considerable distress, especially those with poor fetal prognoses. Ongoing technical developments, such as a reduction of noise, shortening the duration of the MRI, and a more comfortable position in open MRI machines, may have the potential to improve the subjective experiences of women during fetal MRI. LEVEL OF EVIDENCE: III.

Physical, sexual, and psychological violence in a gynaecological-psychosomatic outpatient sample: prevalence and implications for mental health.

OBJECTIVE: The main objective was to assess the prevalence of physical, sexual, or psychological violence in a cohort of patients with gynaecological symptoms who presented at a psychosomatic outpatient clinic. We assessed differences in prevalence rates of gynaecological symptoms and mental health problems in women with and without a history of experiencing violence. STUDY DESIGN: We performed a cohort study of women (n=424) who attended a psychosomatic-gynaecological outpatient clinic during a 6-year-period of time. Information about lifetime victimization, mental health status, and socio-demographic characteristics were systematically obtained through semi-structured interviews. Psychiatric diagnoses were made using questions adapted to the structured interview for DSM-IV. RESULTS: Some form of violence was reported by 39.9%. Of the total sample, physical violence was reported in 25.2%, sexual violence in 13.0%, and psychological violence in 23.8%. Of those with a history of experiencing violence, 26.1% experienced two different kinds of violence, and 14.8% were victims of all three kinds of violence. Perpetrators of physical and psychological violence were, predominantly, the partner or the father. With respect to sexual violence, perpetrators were exclusively male, including family members or friends in more than 80% of all cases. Women with a history of experiencing violence suffered significantly more often from major depressive disorders (29.6%) than those without a history of experiencing violence (16.5%) (p<.002). Post-traumatic stress disorder (PTSD) was significantly more frequent in women with a history of experiencing violence (7.1%) (p<.001). CONCLUSIONS: We found a high lifetime prevalence of different forms of violence toward women in our sample. Perpetrators were most often male family members, highlighting the impact of domestic violence. Our study provides evidence that women who attend a psychosomatic unit should be cautiously screened for a potential history of traumatic violent experiences.

Therapeutic effects of escitalopram and reboxetine in seasonal affective disorder: a pooled analysis.

The monoaminergic neurotransmitters serotonin and noradrenaline have both been implicated in the pathogenesis of seasonal affective disorder (SAD). However, the differential therapeutic value of selective serotonin reuptake inhibitors (SSRI) and selective noradrenaline reuptake inhibitors (NARI) in SAD has not been assessed until now. This study compares data from two open-label trials with similar methodology investigating the SSRI escitalopram and the NARI reboxetine. 20 SAD patients were treated with escitalopram (10-20mg) and 15 patients received treatment with reboxetine (fixed dosage: 8mg) over 6 weeks. Ratings included the structured interview guide for the Hamilton depression rating scale, SAD version (SIGH-SAD), the clinical global impression of severity (CGI-S) and improvement (CGI-I) and the UKU side effect rating scale. Treatment led to a significant reduction in SIGH-SAD score, CGI-S and CGI-I after one week in the reboxetine group and after two weeks in the escitalopram group. SIGH-SAD score was significantly lower in the reboxetine group at weeks 1, 2 and 4 but not at the end of the study. The response rate (SIGH-SAD <50% of baseline value) and the remission rate (SIGH-SAD <8) were not significantly different after 6 weeks of treatment, but the time to response and to remission was significantly shorter in the reboxetine group. The number and severity of side effects were higher in patients treated with reboxetine at all time points. Thus escitalopram and reboxetine were equally effective in treating SAD on all primary and secondary outcome measures. Reboxetine displayed a faster onset of action, but was associated with more pronounced side effects. Further studies comparing SSRI and NARI in SAD are warranted.

Psychiatric morbidity in gynecological and otorhinolaryngological outpatients: a comparative study.

OBJECTIVE: Assessment of the point prevalence of psychiatric disorders in a gynecological outpatient population compared to a control group consisting of otorhinolaryngological outpatients. METHODS: During an 11-month period of time, 150 unselected, consecutive gynecologic outpatients and 150 matched controls (otorhinolaryngological outpatients) were enrolled in the study. Patients were screened for psychiatric disorders using the Patient Health Questionnaire (PHQ). Sociodemographic data, psychiatric and medical history including inpatient treatments and outpatient contacts, and utilisation of the health care system were assessed. RESULTS: Within the gynecological group, 45.3% fulfilled the diagnostic criteria for at least one psychiatric diagnosis according to the PHQ, compared to 27.3% of the otorhinolaryngological control group (P=.002). With respect to distinct diagnoses, gynecological patients suffered significantly more often from somatoform disorders (P=.001) and depressive disorders (P=.003) than controls. Less than half of subjects of either group with any psychiatric diagnosis had ongoing psychiatric or psychotherapeutic treatment. CONCLUSIONS: We found a significant group difference in the number of psychiatric diagnoses between gynecological and otorhinolaryngological female outpatients. Psychiatric disorders may be frequent and unrecognised in women presenting in an outpatient setting, especially in those seeking medical care for gynecological problems. The PHQ may be a useful tool to detect psychiatric disorders even in busy clinical settings.

Clinical seizure lateralization in frontal lobe epilepsy.

PURPOSE: We systematically analyzed the lateralizing value of clinical seizure semiology in patients with frontal lobe epilepsy (FLE). METHODS: We studied the incidence, positive predictive value (PPV), and the lateralizing significance of various clinical symptoms in 228 seizures (s) of 31 patients (p) with medically refractory FLE (17 with left-sided and 14 with right-sided seizure onset). Seizures recorded during prolonged video-EEG monitoring were assessed by two independent reviewers blinded for the patient's clinical data. Analysis was performed both for patients and seizures. RESULTS: Version [16 p (52%); PPV, 94%; p=0.001; 47 s (21%); PPV, 75%; p=0.001], unilateral clonic movements [16 p (52%); PPV, 81%; p=0.021; 32 s (14%); PPV, 81%; p=0.001], unilateral dystonic posturing [eight p (26%); PPV, 75%; p=0.289; 46 s (20%); PPV, 80%; p=0.001], unilateral tonic posturing [10 p (32%); PPV, 80%; p=0.109; 19 s (7.4%); PPV, 79%; p=0.019], and unilateral grimacing [10 p (32%); PPV, 100%; p=0.002; 19 s (8%); PPV, 100%; p=0.001] were of lateralizing significance, indicating a contralateral seizure onset. Asymmetric ending [five p (16%); PPV, 80%; p=0.375; nine s (4%); PPV, 89%; p=0.039] after secondarily generalized tonic-clonic seizures was significantly associated with an ipsilateral seizure onset. Pure ictal vocalizations occurred significantly more frequently in seizures of right hemispheric onset [13 p (42%); PPV, 62%; p=0.581; 63 s (28%); PPV, 73%; p=0. 001], whereas in individual patients, this symptom showed no lateralizing significance. The remaining clinical symptoms (figure 4 sign, unilateral hand automatisms, early head turning, postictal nose wiping, and unilateral eye blinking) were not of lateralizing significance in our patients. The results of clinical seizure lateralization corresponded with the final lateralization of the seizure-onset zone in 81% of our patients. CONCLUSIONS: Clinical seizure semiology can provide correct information on the lateralization of the seizure-onset zone in >80% of patients with medically refractory frontal lobe epilepsy.

Prenatal care: the patient's perspective. A qualitative study.

OBJECTIVES: To investigate the subjective experiences and perceptions of the prenatal care system for women following a prenatal diagnosis and to assess the factors related to dissatisfaction with medical treatment. METHODS: Data derived from a follow-up investigation in fifty women following a prenatal diagnosis is presented. Women were asked to give written comments concerning their feelings and experiences during their time at the prenatal care unit. A qualitative content analysis was performed in order to examine the patients' perceptions and expectations of the prenatal care management and to seek potential associations of certain attitudes with socio-demographic, clinical, or psychological characteristics. Womens' comments were coded within established categories including 'satisfaction', 'dissatisfaction' and 'communicated emotionality'. RESULTS: A high proportion of women were found to be dissatisfied with the physicians' attitudes (42%), the amount of information provided (46%), and medical staffs' attitudes (30%). One criticism, in particular, concerned a lack of communication skills in doctors and medical staff members. Forty-eight percent of our study population mentioned that they had benefited from psychological support. 'Nullipara' was the only variable associated with dissatisfaction with the received prenatal care. CONCLUSIONS: The results of the study suggest that the high degree of discontent found in prenatal care patients could at least in some part be alleviated by implementation of communication training and supervision services for prenatal care workers. Moreover, nullipara may constitute a particular vulnerable subgroup that may need special attention and support. However, given the qualitative nature of our study, our results warrant replication in further empirically based research.