Quality of life after coronary artery bypass graft & percutaneous transluminal coronary angioplasty: A follow up study from India.

Coronary artery bypass graft (CABG) and percutaneous transluminal coronary angioplasty (PTCA) are treatments of choice for coronary artery disease. Quality of life (QoL) is an important factor in determining optimum treatment. This study was aimed to compare changes in QoL, six months post procedure, between CABG and PTCA, and to understand the confounding effect of various contributing factors. Thirty stable angina patients each in CABG and PTCA groups, were followed up for six months. QoL was assessed with WHO-QoL-BREF. Depression was rated on the Hamilton Depression Rating Scale. Changes in QoL and depression within and between CABG and PTCA groups were compared. Multinomial logistic regression was used to measure the predictive strength of treatment type (CABG and PTCA) on QoL, controlling for significant confounders. Although scores of QoL and depression significantly changed over time in both the groups, time×group interaction did not reach to a significance. Significant confounding effects of diabetes (P<0.01), hypertension (P<0.05) and diet restriction (P<0.05) were found. Controlling for confounding effects of these factors, group distribution to PTCA, compared to CABG, significantly predicted greater improvements in QoL (P<0.01).

Adjuvant low-frequency rTMS in treating auditory hallucinations in recent-onset schizophrenia: a randomized controlled study investigating the effect of high-frequency priming stimulation.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) has been found to be effective in reducing frequency and duration of auditory verbal hallucinations (AVH). Priming stimulation, which involves high-frequency rTMS stimulation followed by low-frequency rTMS, has been shown to markedly enhance the neural response to the low-frequency stimulation train. However, this technique has not been investigated in recent onset schizophrenia patients. The aim of this randomized controlled study was to investigate whether the effects of rTMS on AVH can be enhanced with priming rTMS in recent onset schizophrenia patients. METHODS: Forty recent onset schizophrenia patients completed the study. Patients were randomized over two groups: one receiving low-frequency rTMS preceded by priming and another receiving low-frequency rTMS without priming. Both treatments were directed at the left temporo-parietal region. The severity of AVH and other psychotic symptoms were assessed with the auditory hallucination subscale (AHRS) of the Psychotic Symptom Rating Scales (PSYRATS), the Positive and Negative Syndrome Scale (PANSS) and the Clinical Global Impression (CGI). RESULTS: We found that all the scores of these ratings significantly reduced over time (i.e. baseline through 1, 2, 4 and 6 weeks) in both the treatment groups. We found no difference between the two groups on all measures, except for significantly greater improvement on loudness of AVH in the group with priming stimulation during the follow-ups (F = 2.72; p < .05). CONCLUSIONS: We conclude that low-frequency rTMS alone and high-frequency priming of low-frequency rTMS do not elicit significant differences in treatment of overall psychopathology, particularly AVH when given in recent onset schizophrenia patients. Add on priming however, seems to be particularly better in faster reduction in loudness of AVH.

Resting State Dense Array Gamma Oscillatory Activity as a Response Marker for Cerebellar-Repetitive Transcranial Magnetic Stimulation (rTMS) in Schizophrenia.

BACKGROUND: As cerebellum and its abnormalities have been implicated in the pathophysiology of schizophrenia, repetitive transcranial magnetic stimulation (rTMS) of this alternate site has been suggested as a novel target for treating patients with this disorder. As resting state gamma activity measures functional brain connectivity, it could be used as a specific treatment marker. AIM: To investigate the effect of cerebellar-rTMS on resting state gamma activity, while studying its efficacy in recent onset schizophrenia patients. METHODS: This rater-blinded prospective study was completed by 11 schizophrenia patients. They received 10 sessions of high-frequency (theta patterned) rTMS to midline cerebellum over 2 weeks. Resting state EEG was recorded using high (192-channel) resolution EEG at baseline and post rTMS. Gamma spectral power was calculated using fast Fourier transformation, Hanning window averaged over 8 scalp segments corresponding 8 lobes. Clinical improvement rated on the Positive and Negative Syndrome Scale and depressive symptoms assessed using the Calgary Depression Scale for Schizophrenia were other outcome variables. Nonparametric statistics were used. RESULTS: Over the treatment course, significant reduction was seen on negative syndrome and depression scores. Gamma spectral power in left frontal and temporal segments reduced significantly. Spearman correlation analysis showed that percentage reduction in psychopathology scores had significant positive correlation with percentage reduction in gamma spectral power. CONCLUSIONS: Cerebellar-rTMS might be an effective adjunct to treat intricate and lingering negative and affective symptoms. Resting state gamma spectral power in frontal and temporal regions might be used as a biomarker for treatment response.

Acute dystonia, akathisia, and parkinsonism induced by ziprasidone.

Ziprasidone is a second-generation antipsychotic with a lower propensity to cause extrapyramidal adverse effects that are seen at higher doses. We report a patient who developed acute dystonia, parkinsonism, and severe akathisia with ziprasidone 80 mg/d. These adverse effects subsided after dose reduction and specific treatment for akathisia and parkinsonism.

Acute high dose lithium-induced exacerbation of obsessive compulsive symptoms.

Obsessive compulsive disorder (OCD) is a chronic neuropsychiatric disorder whose pathophysiology is linked to serotonergic dysfunction. More recently, the role of glutamate has also been posited. Lithium is used as an adjunctive for the treatment of OCD which is found to enhance serotonergic transmission. We present a case of OCD who was on stable dose of sertraline developed exacerbation of obsessive compulsive symptoms with acute high dose of lithium but improved after dose reduction.

Dose-dependent olanzapine-induced myoclonus.

Second-generation antipsychotics (SGA), mainly clozapine have been reported to induce myoclonus. Although olanzapine-induced myoclonus is reported, dose-dependent response has not been described. We report dose-related olanzapine-induced myoclonus in an early onset schizophrenia patient. We also suggest certain management strategies for such adverse side effects.

Exacerbation of auditory verbal hallucinations with adjunctive high-frequency cerebellar vermal repetitive transcranial magnetic stimulation in schizophrenia: a case report.

In schizophrenia, novel target sites for repetitive transcranial magnetic stimulation (rTMS), such as the cerebellum, are proposed to have a putative therapeutic role in treatment-resistant cases. We present a case of treatment-resistant schizophrenia that showed worsening of auditory verbal hallucinations after receiving high-frequency cerebellar vermal rTMS. We propose that cerebellar vermal rTMS modulates neuronal networks, causing activation in temporoparietal areas, which results in worsening of auditory verbal hallucinations.

Personality correlates of accident-proneness in auto-rickshaw drivers in India.

OBJECTIVE: We examined the personality correlates of accident-proneness of auto-rickshaw drivers in the Indian city of Ranchi. METHODS: This was a cross-sectional study in which 50 male drivers aged 18-50 years, selected randomly from a list of licensed auto-rickshaw drivers in Ranchi, were assessed with a Hindi version of Cattell's 16 Personality Factors (16-PF) Questionnaire. RESULTS: There was a significantly higher frequency of breaking rules, crossing speed limits, substance use and a trend towards a higher frequency of carrying extra persons (i.e., more than recommended) in accident-prone drivers. There was significant negative correlation of accident-proneness with 16-PF factors such as reasoning, rule consciousness, apprehension and emotional stability. CONCLUSION: Personality characteristics with lower scores of reasoning, rule consciousness, apprehension and emotional stability are common in commercial auto-rickshaw drivers with high accident-proneness.

Depressive disorders in school children of suburban India: an epidemiological study.

PURPOSE: There is a dearth of research on the prevalence of depressive disorders in children from suburban and rural areas in the Indian subcontinent. Therefore, the present study was aimed at assessing the prevalence of depressive disorders and the associated risk factors in the primary and secondary school children in suburban India. METHODS: This was a cross-sectional, school-based epidemiological study involving 1,851 children from standard I to VII age group. Schedule for Affective Disorders and Schizophrenia for School Age Children (K-SADS-PL), a semi-structured interview was used to diagnose depression in this sample. RESULTS: Using K-SADS-PL, prevalence of depressive disorder was 3.13% (n = 58); major depressive disorder was diagnosed in 15 (0.81%), dysthymia in 28 (1.51%) and depressive disorder NOS in 15 (0.81%). Age (OR 1.396, CI 1.121-1.738), class attendance (OR 0.251, CI 0.103-0.613), family history of psychiatric illness (OR 0.204, CI 0.069-0.605) and birth complications (OR 0.128, CI 0.029-0.558) emerged as significant predictors of depression; the model explained 24.1-32.3% of the variance in this sample. CONCLUSION: The present study confirms the findings from previous studies that childhood depression is a distinct diagnostic entity affecting a significant number of children and adolescents.

Motor cortical plasticity in adolescents with early onset schizophrenia: A TMS-EMG study assessing the perturbation effect of intermittent and continuous theta burst stimulation.

BACKGROUND: Neuroplasticity in adolescents is distinct from that of adults. Literature pertaining to neuroplasticity in schizophrenia is limited to adult populations. AIM: We aimed to assess baseline (or resting) cortical excitability and cortical plasticity in adolescents with schizophrenia using the transcranial magnetic stimulation-electromyography (TMS-EMG) protocol. METHODS: Twenty adolescent cases with schizophrenia and 20 age and gender matched healthy controls were studied using a crossover design. Single pulse TMS elicited resting motor threshold (RMT) and motor evoked potentials (MEPs) were assessed. Cortical plasticity was determined by tracking MEPs after a single session continuous theta burst stimulation (cTBS) and intermittent theta burst stimulation (iTBS) up to 120 min at 12 intervals. RESULTS: Baseline (or resting) cortical excitability was found to be significantly lower in cases compared with controls. Response patterns to cTBS and iTBS were similar between the crossover. While cTBS led to inhibitory response, iTBS had an excitatory effect in both the groups. In the cases, while cTBS led to significantly greater initial inhibitory response, iTBS led to significantly lower excitatory response, compared with controls. The time taken to return to baseline excitability was significantly longer after receiving cTBS for cases, compared with controls. CONCLUSIONS: iTBS and cTBS lead to excitatory and inhibitory response, representing classical long-term depression and long-term potentiation effects, respectively, in both cases and controls. We conclude that adolescents with schizophrenia have significantly lower baseline (resting) cortical excitability as well as significantly greater inhibitory plasticity; excitatory plasticity is significantly lower.

Metformin for olanzapine-induced weight gain: a systematic review and meta-analysis.

Olanzapine is an atypical antipsychotic that is useful in schizophrenia and bipolar affective disorder, but its use is associated with troublesome weight gain and metabolic syndrome. A variety of pharmacological agents has been studied in the efforts to reverse weight gain induced by olanzapine, but current evidence is insufficient to support any particular pharmacological approach. We conducted a systematic review and meta-analysis of randomized controlled trials of metformin for the treatment of olanzapine-induced weight gain. Systematic review of the literature revealed 12 studies that had assessed metformin for antipsychotic-induced weight gain. Of these, four studies (n= 105) met the review inclusion criteria and were included in the final analysis. Meta-analysis was performed to see the effect size of the treatment on body weight, waist circumference and body-mass index (BMI). Weighted mean difference (WMD) for body weight was 5.02 (95% CI 3.93, 6.10) kg lower with metformin as compared with placebo at 12 weeks. For waist circumference, the test for heterogeneity was significant (P= 0.00002, I(2) = 85.1%). Therefore, a random effects model was used to calculate WMD, which was 1.42 (95% CI 0.29, 3.13) cm lower with metformin as compared with placebo at 12 weeks. For BMI, WMD was 1.82 (95% CI 1.44, 2.19) kg m(-2) lower with metformin as compared with placebo at 12 weeks. Existing data suggest that short term modest weight loss is possible with metformin in patients with olanzapine-induced weight gain.

Factor structure of manic symptoms in adolescents.

OBJECTIVE: To identify the factor structure of manic symptoms in adolescents as assessed by the Scale for Manic States (SMS). METHOD: Pattern of symptoms was assessed in a group of 100 adolescents with a diagnosis of manic episode as defined by the International Classification of Diseases, 10th revision - Diagnostic Criteria for Research. A principal component analysis of the broad range of psychiatric symptoms covered by the SMS was conducted. RESULTS: Seven eigenvalues were greater than unity, and parallel analysis revealed 5 factors, whereas scree plot was inconclusive. Five-factor solution as obtained by parallel analysis was chosen, which described our data appropriately and were clinically relevant. The 5 factors were: aggressive overactivity, dysphoria, psychosis, hedonia, and thought retardation. These captured 58.14% of the total variance. CONCLUSIONS: These 5 factors explain the clinical dimensions in adolescent mania similar to those of the adult population. Nevertheless, certain features, such as presence of psychosis along with euphoric mood and thought retardation, distinguish adolescent from adult mania.

Complex partial status epilepticus: an unusual presentation.

Nonconvulsive status epilepticus (NCSE) is not uncommon, especially in the elderly population. It can occasionally present as confusion, personality change, coma, subtle motor activity and psychosis, thus causing diagnostic difficulties. We report an unusual case of NCSE which presented as psychosis-like episodes at regular intervals. The confirmation of diagnosis was aided by serial electroencephalography.

Asperger disorder in adults.

Asperger disorder was first described in 1944 by the Austrian pediatrician, Hans Asperger. It was introduced as a separate diagnostic category from autistic disorder in DSM-IV and ICD-10. The pattern of comorbidity in Asperger disorder is different from autistic disorder, with a higher level of psychosis, violent behavior, anxiety, and mood disorders. We present three cases of Asperger disorder diagnosed for the first time in adulthood, with psychosis being the predominant reason for the referral. In each case, the psychosis improved with antipsychotic treatment, although core autistic symptoms remained the same.

Memory changes following adjuvant temporo-parietal repetitive transcranial magnetic stimulation in schizophrenia.

OBJECTIVE: The use of repetitive transcranial magnetic stimulation (rTMS) in schizophrenia has shown improvement as well as deficits in memory. Though most studies had focused on dorsolateral prefrontal cortex only, but impact of rTMS on cognitive functions remain inconclusive. The need of the study is to assess the impact of rTMS on memory in schizophrenia. MATERIALS AND METHODS: Forty right-handed male patients with schizophrenia were included by purposive sampling and rated on Positive and Negative Syndrome Scale (PANSS) before starting the rTMS treatment with the experimental group. Low frequency 1 Hz rTMS including 1200 stimulations were given over temporo-parietal cortex for 20 min as add on to medications. At the end of 10 session treatment (5 days a week for 2 weeks), the patients were re-evaluated. RESULTS: A total of 39 patients (20 for experimental group and 19 for control group) with mean age of 29.70 ± 9.05 and 31.26 ± 7.78 years, respectively, shows significant difference to pre- and post-treatment mean PANSS score in positive, negative and general psychopathology domains. The pre- and post-treatment mean Postgraduate Institute Memory Scale Scores with multivariate repeated measures analysis of variance revealed significant improvements in all memory domains (P < 0.01) except remote memory in both experimental and control groups. CONCLUSION: RTMS in combination with antipsychotics has shown improvement in psychopathology in patients of schizophrenia without any deterioration of memory.

Bipolar affective disorder associated with thenar hypoplasia: is lithium safe?

Thenar hypoplasia has been described to occur as a part of radial longitudinal deficiency syndromes and occasionally related to Holt-Oram syndrome in which both cardiac and skeletal abnormalities co-occur. We describe a case with bilateral thenar hypoplasia, which resembles a milder variety of Holt-Oram syndrome, who developed bradycardia after exposure to lithium at therapeutic doses.

Factor structure of manic symptoms.

OBJECTIVE: The purpose of the present study was to identify the factor structure of manic symptoms as assessed by the Scale for Manic States (SMS). METHOD: The pattern of symptoms in a group of 225 adults with an ICD-10-DCR diagnosis of manic episode was studied. A factor analysis was conducted of the broad range of psychiatric symptoms covered by SMS. A principal component analysis followed by oblimin rotation was performed. RESULTS: Six eigenvalues were greater than unity and parallel analysis indicated four factors. After observing the scree plot a five-factor solution seemed appropriate. Nevertheless, a six-factor solution was chosen that described the data appropriately and was clinically relevant. The six factors (psychosis, irritability aggression, dysphoria, accelerated thought stream, hedonia, and hyperactivity) captured 59.29% of the total variance. CONCLUSION: A six-factor solution explains the clinical dimensions of mania in the present sample and dysphoria appeared as a separate factor.

Musical obsession or pseudohallucination: electrophysiological standpoint.

Reported herein is a case of obsessive-compulsive disorder with persistent and distressing musical obsessions along with other symptoms. Advanced source analysis of electroencephalographic data indicated high spectral power over the bifrontal region. The musical symptoms were resistant to pharmacotherapy but there was some reduction in frequency and duration of musical obsessions with thought-stopping technique.