Landmark-based morphometric analysis of first-episode schizophrenia

BACKGROUND

The goal of this investigation was to utilize landmark-based shape analysis and image averaging to determine the sites and extent of specific structural changes in first-episode schizophrenia.

METHODS

Neuroanatomic structures identified on midsagittal magnetic resonance imaging (MRI) scans were compared between 20 patients with schizophrenia and 22 normal control subjects. The difference between averaged landmark configurations in the two groups was visualized as a shape deformation by a thin-plate spline and through averaged MRI images for both groups.

RESULTS

A shape difference was found to be statistically significant; by inspection, it is contrast between differences in two closely abutting regions, involving primarily the posterior corpus callosum and upper brain stem--the "focus" is the relation between them.

CONCLUSIONS

The findings are consistent with prior studies suggesting involvement in schizophrenia of the corpus callosum and the limbic structures contributing to the corpus callosum; the possibility of local pathology primarily involving the brain stem cannot be excluded. The methods of landmark-based shape analysis and image averaging utilized in this study can complement the "region-of-interest" method of investigating morphometric abnormalities by characterizing the spatial relationships among structural brain abnormalities in schizophrenia.

Cholinergic aspects of schizophrenia

While increased dopamine activity is central to our current understanding of the pathophysiology of schizophrenia, dysregulation of a single neurotransmitter is unlikely to explain the disorder adequately. It is argued here that the muscarinic aspects of schizophrenia should be reassessed for a number of reasons. These include current evidence that cholinergic modulation affects both positive and negative symptoms, and neuroendocrine and polysomnographic data that suggest an increased muscarinic cholinergic activity in schizophrenia. In addition, the interactions between the dopaminergic and cholinergic systems are becoming better understood and appear to occur especially in regions that are thought to be relevant is schizophrenia. The fact that the highest affinity of clozapine, with its unique therapeutic profile, is to the muscarinic receptor encourages further evaluation. Finally, the use of anticholinergic agents to treat extrapyramidal side-effects and the fact that many antipsychotic agents have intrinsic anticholinergic activity suggest that the role of the cholinergic system in schizophrenia needs to be more clearly delineated.

Combined electroconvulsive therapy and clozapine in treatment-resistant schizophrenia

1. To assess the efficacy and safety of combining electroconvulsive therapy (ECT) and clozapine in patients with treatment-resistant schizophrenia, the authors reviewed use of this combination in four treatment-resistant schizophrenic inpatients and one inpatient with schizophrenia who was intolerant of clozapine doses needed to control her psychosis. 2. The combination of clozapine and bilateral ECT was modestly effective in two treatment-resistant patients and markedly effective in three patients. There was significant overall improvement in patients' Clinical Global Impression (CGI) and Global Assessment of Functioning (GAF) scores (p < 0.005 and p < 0.0004, respectively), however in patients where marked symptomatic improvement was noted, effects were not sustained. 3. One of the patients that showed dramatic yet transient improvement followed by relapses received maintenance ECT but relapsed despite this. 4. The authors saw no adverse effects in connection with the combination of ECT and clozapine. 5. Supplementing clozapine with a course of bilateral ECT appears to be safe and is effective in some patients with refractory schizophrenia, however its beneficial effects may be short-lived. The long-term impact of ECT on the course of schizophrenia in patients incompletely responsive to clozapine is not fully elucidated.

An epidemiological study of blood pressure in school children (5-14 years) in Delhi

Distribution patterns of blood pressure were studied in a randomised sample of 10,215 school children (5,709 boys 4,506 girls) in the age group 5-14 years in Delhi. The mean values of systolic and diastolic blood pressure (SBP and DBP) increased with age in both sexes. The cut-off points for high blood pressure were based on average SBP and/or DBP values of 95th percentile or greater for each age. The values for SBP ranged from 70 mm Hg to 140 mm Hg and for DBP from 36 mm Hg to 100 mm Hg for the age group 5-9 years. In the age group 10-14 years, the values for SBP and DBP ranged from 72 mm Hg to 160 mm Hg and from 46 mm Hg to 120 mm Hg, respectively. The prevalence of hypertension (systolic, diastolic or both) was 11.9 percent in boys and 11.4 percent in girls, an insignificant difference. Anthropometric variables like height, weight and body mass index showed positive correlation with systolic as well as diastolic blood pressure but the waist-hip ratio showed negative correlation coefficient with blood pressure. Family history of hypertension in one or both the parents was present in 20.4 percent children with high blood pressure compared to 6.8 percent in normotensives. Family history or diabetes was also significantly higher in hypertensive children (5.4%) than in normotensives (3.1%).

Crack Arrest and Multiple Cracking in Glass Through the Use of Designed Residual Stress Profiles

A processing approach has been identified and reduced to practice in which a residual stress profile can be designed such that cracks in a brittle material are arrested or grow in a stable manner. In the approach, cracks in the body encounter an increase in the magnitude of residual compression as the crack propagates. If correctly designed, the process increases strength and significantly decreases strength variability. This approach was demonstrated for a silicate glass, and multiple cracking was observed as a forewarning of the final failure. Normally, such glasses would fail catastrophically with the propagation of a dominant crack.

Hemoglobin endocytosis in Leishmania is mediated through a 46-kDa protein located in the flagellar pocket

Four lines of evidence indicate that a specific high affinity binding site on the surface of Leishmania donovani promastigotes mediates rapid internalization and degradation of hemoglobin. 1) Binding and uptake of 125I-hemoglobin by Leishmania followed saturation kinetics and were competed by unlabeled hemoglobin but not by globin or hemin or other heme- or iron-containing proteins. 2) Immunogold labeling studies revealed that, at 4 degreesC, hemoglobin binding was localized in the flagellar pocket of the promastigotes. Indirect immunofluorescence assays showed that, at 37 degreesC, the bound hemoglobin in such cells entered an endocytic compartment within 2 min and dispersed throughout the cell body by 15 min. 3) After incubation with hemoglobin-gold conjugates at 25 degreesC or 37 degreesC, the particles accumulated in discrete intracellular vesicles. 4) A single biotinylated protein of 46 kDa was revealed when solubilized membranes from surface biotinylated intact Leishmania adsorbed by hemoglobin-agarose beads were subjected to SDS-polyacrylamide gel electrophoresis and Western blotting with avidin-horseradish peroxidase. Considered together, these data indicate that this 46-kDa protein on the cell surface of L. donovani promastigotes mediates the binding of hemoglobin and its rapid internalization through a vesicular pathway characteristic of receptor-mediated endocytosis.

Effects of antipsychotic treatment on polysomnographic measures in schizophrenia: a replication and extension

OBJECTIVE

The authors sought to replicate and extend previous observations of improvement in some EEG sleep measures during the course of antipsychotic treatment in schizophrenia patients.

METHOD

Fourteen medication-free patients with schizophrenia underwent 2 nights of sleep EEG monitoring before and after 3-4 weeks of treatment with clinically determined doses of haloperidol or thiothixene.

RESULTS

Measures of sleep continuity improved consistently. REM latency increased, although five of 14 patients continued to exhibit short REM latencies (less than 60 minutes). Stage 3 sleep increased during neuroleptic treatment, while stage 4 sleep did not change.

CONCLUSIONS

These data demonstrate partial improvement of some but not all EEG sleep measures in schizophrenic patients through the course of neuroleptic treatment. They suggest that shortened REM latency and disturbed sleep continuity might represent reversible state abnormalities, while reduced slow-wave sleep may represent a more persistent trait abnormality in schizophrenia.

Optic neuritis following albendazole therapy for orbital cysticercosis

PURPOSE

To report the occurrence of optic neuritis following oral albendazole therapy for orbital cysticercosis.

METHODS

Two patients having definitively diagnosed orbital cysticercosis at the orbital apex developed an acute visual loss 1 week after initiation of oral albendazole. Ultrasonography and magnetic resonance imaging determined that the cause was optic neuritis due to disorganization of the cyst with inflammation of the adjacent optic nerve.

RESULTS

Oral corticosteroids (prednisolone 1 mg/kg per day) given for a period of 4 weeks led to resolution of the optic neuritis, with full visual recovery.

CONCLUSION

Corticosteroids should be given in addition to albendazole in the treatment of orbital cysticercosis when cysts are in close proximity to the optic nerve.

Mutational analysis of the PTEN gene in head and neck squamous cell carcinoma

Loss of heterozygosity (LOH) at chromosome band 10q23 occurs frequently in a wide variety of human tumors. A recently identified candidate tumor suppressor gene, PTEN located on 10q23, is mutated in multiple advanced cancers. To explore whether PTEN is associated with human squamous cell carcinoma of the head and neck (SCCHN), DNAs from both normal muscle and tumor tissue in 19 SCCHN were used for detecting LOH at chromosome 10q23 and mutational analysis of PTEN by direct polymerase chain reaction (PCR)-DNA sequencing. LOH at 10q23 was identified in 6/15 SCCHN. Mutation of PTEN was identified in 3/19 SCCHN. Of these 3 patients, 2 had stage IV disease; the third patient, with recurrent, metastatic and stage III disease, showed a 36 bp germline heterozygous deletion within intron 7. Furthermore, a missense mutation at codon 501 (TCT --> TTT: Ser --> Phe) in exon 8 was also found in tumor from the same patient. Our results suggest that PTEN may play a role in the genesis of some SCCHNs.

Mutational analysis of the PTEN gene in head and neck squamous cell carcinoma

Loss of heterozygosity (LOH) at chromosome band 10q23 occurs frequently in a wide variety of human tumors. A recently identified candidate tumor suppressor gene, PTEN located on 10q23, is mutated in multiple advanced cancers. To explore whether PTEN is associated with human squamous cell carcinoma of the head and neck (SCCHN), DNAs from both normal muscle and tumor tissue in 19 SCCHN were used for detecting LOH at chromosome 10q23 and mutational analysis of PTEN by direct polymerase chain reaction (PCR)-DNA sequencing. LOH at 10q23 was identified in 6/15 SCCHN. Mutation of PTEN was identified in 3/19 SCCHN. Of these 3 patients, 2 had stage IV disease; the third patient, with recurrent, metastatic and stage III disease, showed a 36 bp germline heterozygous deletion within intron 7. Furthermore, a missense mutation at codon 501 (TCT --> TTT: Ser --> Phe) in exon 8 was also found in tumor from the same patient. Our results suggest that PTEN may play a role in the genesis of some SCCHNs.

Production of cytotoxic factor by peripheral blood mononuclear cells (PBMC) in patients with dengue haemorrhagic fever

A unique cytokine, human cytotoxic factor (hCF), has been shown to occur in the sera of patients with dengue fever (DF) and dengue haemorrhagic fever (DHF). The present study was undertaken to investigate the ability of fresh PBMC of such patients to produce hCF. The PBMC were cultured for 24 h and the culture supernatants (CS) were analysed for the presence of hCF by cytotoxicity assay, competitive ELISA and dot blot tests. In 90% of 246 cases CS were positive for hCF by the three tests. CS were positive for hCF in PBMC collected from days 1-20 of illness but not at later periods. Higher cytotoxic activity was observed in CS of days 1-4 of illness and was highest in cases of DHF grade IV and lowest in cases of DF. Dot blot hybridization of RNA extracted from the PBMC of the patients showed the presence of mRNA for hCF in 94% of cases. A similar number of patients showed the presence of hCF in situ in the PBMC smears by fluorescent antibody technique. hCF was found only in CD4+ T cells. The findings thus present direct evidence of the production of hCF by CD4 T cells of cases of DF/DHF.

New atypical antipsychotic medications

Conventional antipsychotics were the first treatments effective in controlling psychotic symptomatology and revolutionized management of psychotic disorders when introduced in the 1950's. The use of these agents has, however, been marked by several shortcomings, including limited efficacy in treating the negative and cognitive symptoms of schizophrenia, and by significant extrapyramidal and other side-effects. There appears to be justifiable excitement about the introduction of the newer atypical antipsychotics, which may represent the second pharmacological revolution in the treatment of psychotic disorders. But how are these agents really different from their neuroleptic predecessors? How is their pharmacological profile different? Are there clear differences in efficacy? How do side-effect profiles differ? These issues are reviewed in this manuscript. Atypical agents are pharmacologically distinct from their neuroleptic predecessors. Their primary advantage is their superior side effect profiles, particularly with regard to EPS. The implications of EPS reduction touch virtually every domain of pathology in schizophrenia, including short- and long-term movement disorders, negative symptoms, noncompliance, relapse rate, cognitive dysfunction, and dysphoria. It should be emphasized that while atypical antipsychotics share some clinical attributes, there are substantial clinical differences between them as well. These differences are reviewed in this article as well. The drugs' unique profiles with regard to other side effects may make it possible to tailor treatment more individually to patients. Further refinement of our understanding of the clinical utility of these drugs awaits their widespread use in mainstream clinical settings. Controlled studies comparing them to one another should be of particular interest.

Do atypical antipsychotic medications favorably alter the long-term course of schizophrenia?

Schizophrenia is characterized by the greatest degree of clinical deterioration in the first decade following onset of psychosis; in fact, deterioration begins even prior to the onset of frank psychotic symptomatology. While somewhat controversial, it appears that effective early antipsychotic treatment might limit the extent of such deterioration. The newer, atypical antipsychotics such as clozapine, risperidone, olanzapine and quetiapine appear to have antipsychotic efficacy at least equal to the traditional neuroleptics, but with a much more favorable side effect profile. Clozapine is also effective in treating neuroleptic-refractory schizophrenic patients. Data suggest that in comparison to conventional agents, treatment with atypical antipsychotics may be associated with a more benign course of schizophrenic illness. Whether these atypical antipsychotics are associated with greater efficacy in limiting clinical deterioration in schizophrenic illness than traditional neuroleptics is, however, unclear. The following questions will be addressed in this paper: (i) Do atypical antipsychotics differ from traditional neuroleptics in modifying the natural course of symptomatology in schizophrenic illness? (ii) Do atypical antipsychotics differ from typical neuroleptics in modifying the natural course of neurobiological and cognitive abnormalities in schizophrenic illness? (iii) Do atypical antipsychotics differ from typical neuroleptics in modifying the natural course of psychosocial dysfunction in schizophrenic illness? (iv) Are there differences between typical and atypical antipsychotics with regard to their effects on the cost of care and resource utilization? The implications of the answers to these questions for the long-term treatment of schizophrenia will be discussed.

Topical aspirin provides protection against galactosemic cataract

Effect of twice daily administration of aspirin eyedrops on the onset and progression of cataract induced by 30% galactose diet was studied. On the 30th day of galactose feeding while all control group rats showed complete stage IV opacity, those receiving aspirin eyedrops showed only mild cataractous changes of stage I. In vitro studies showed that addition of aspirin to the medium significantly decreased dulcitol formation (p < 0.01) and maintained glutathione levels (p < 0.02). Intraocular penetration studies using isolated goat cornea showed excellent penetration by salicylate indicating feasibility of topical administration. The results of the present study demonstrate that topical aspirin possesses significant anticataract activity in galactosemic cataract.

Relationship of seizure duration to antidepressant efficacy in electroconvulsive therapy

BACKGROUND

A relationship between the anticonvulsant and antidepressant properties of electroconvulsive therapy (ECT) has been hypothesized. The goal of this study was to see whether the anticonvulsant effects of ECT could be measured in a clinical setting and whether there was any relationship between the anticonvulsant effects of ECT and the antidepressant response to it.

METHODS

We examined the temporal relationship between change in seizure duration (as an index of anticonvulsant activity) and improvement in Hamilton Rating Scale for Depression scores in a retrospective sample of 114 depressed patients who received 145 courses of ECT. A linear mixed effects model was utilized for analysis so that the repeated measures nature of the data could be taken into account.

RESULTS

Both seizure duration and depression scores decreased significantly through the course of ECT. However, no evidence was found for a relationship between decrease in seizure duration and clinical improvement as measured by Hamilton ratings.

CONCLUSIONS

The process underlying the reduction in seizure duration through a course of ECT may not be related to antidepressant efficacy.

Does neuroanatomy predict ECT response?

1. Structural neuropathologic abnormalities have been associated with severe psychiatric illnesses, including bipolar disorder, major depressive disorder, and schizophrenia. In the latter, ventricular enlargement has been variably associated with symptom severity and poor treatment response. In patients with severe depressive disorders, the relationship between cortical and subcortical pathology and ventricle enlargement, symptom severity, and response to treatment is far from clear. 2. The present study investigated the relationship between structural CNS pathology, symptom severity and treatment response in patients undergoing ECT. It was hypothesized that patients with greater neuroanatomic abnormalities would demonstrate greater initial symptom severity and poorer response to ECT. 3. The subjects were 57 patients with unipolar or bipolar depression admitted for ECT treatment. Symptom severity was quantified using the Hamilton Depression Rating Scale (HRSD) at baseline and post-ECT. 4. Lateral and third ventricle-brain ratio (LVBR, 3VBR) were determined from CT scans and cortical atrophy was rated by a faculty neuroradiologist. 5. Contrary to our first hypothesis, structural pathology was not associated with baseline symptom severity. In terms of treatment response, the number of treatments required to achieve benefit was correlated with larger 3VBR; CT variables were not related to total post-treatment or change in HRSD score. Third ventricle enlargement may be an index of generalized pathology or regional brainstem abnormalities that influence ECT response rate by limiting individual seizure efficacy or neurochemical responsiveness, thereby necessitating a greater number of ECT treatments, without significant impact on overall response.

Non-Hodgkin's lymphoma masquerading as empyema thoracis

Non-hodgkin's lymphoma has varied presentations. Malignant lymphoma arising in chronic pyothorax is very rare and has been reported from Japan. We report a case of non-hodgkin's lymphoma presenting as empyema thoracis.

PET study of greater visual activation in schizophrenia

OBJECTIVE

The authors tested the hypothesis that photic visual stimuli cause a greater blood flow activation response in subjects with schizophrenia than in normal subjects.

METHOD

Eleven medicated patients with schizophrenia and 10 normal subjects were studied with [15O]H2O positron emission tomography to measure perfusion during photic stimulation at four different rates.

RESULTS

The activation at three out of four rates of visual stimulation was greater for the patients with schizophrenia than it was for the normal subjects.

CONCLUSIONS

Further investigation into the mechanisms of activation during sensory stimulation in schizophrenia is warranted.

Sleep-onset rapid eye movement after electroconvulsive therapy is more frequent in patients who respond less well to electroconvulsive therapy

The response to electroconvulsive therapy (ECT) was monitored with sleep polysomnography studies (SPS) performed pre- and post-ECT, in 25 patients with major depressive disorder (MDD). Patients included in this study met research diagnostic criteria for MDD and had been free of psychotropic medication for at least 10 days before SPS were performed. We compared ECT responders and nonresponders on SPS, demographic, and clinical parameters. Many SPS parameters, regardless of the clinical response, changed significantly with ECT. The presence of delusions was significantly associated with SOREM post-ECT. The presence of sleep-onset REM periods post-ECT was associated with poor response to ECT. SPS performed during a course of ECT may help identify patients at risk of responding less well to this modality of treatment.

The effect of paroxetine on thiothixene pharmacokinetics

OBJECTIVE

In this study healthy volunteers received thiothixene with and without a 3-day pretreatment with paroxetine to determine if paroxetine decreased the clearance of thiothixene.

METHOD

Ten healthy medication-free volunteers (4 women and 6 men, mean age 38 +/- 12 years) were randomized to receive a single 20 mg oral dose of thiothixene on two separate occasions. On one occasion thiothixene was given concurrently, and following 3 days of pre-treatment with oral paroxetine (20 mg/day). On the other occasion thiothixene was given without paroxetine pre-treatment. The two study days were separated by a minimum period of 2 weeks. On both study days, after the administration of thiothixene, 10 ml blood samples were collected over the next 72 h.

RESULTS

None of the pharmacokinetic parameters of thiothixene were significantly altered by a 3-day treatment with paroxetine.

DISCUSSION

It is likely that the CYP2D6 isoenzyme is not responsible for a high proportion of thiothixene clearance, but one cannot exclude the possibility that a longer paroxetine pretreatment might have caused some inhibition of thiothixene clearance.

Aerosol delivery during continuous nebulization

BACKGROUND AND OBJECTIVES

Continuous administration of aerosolized beta 2-agonists has been suggested as an effective treatment for severe reversible airways disease. To facilitate continuous therapy and avoid a feed system for small-volume nebulizers (SVNs), a large-volume medication nebulizer (Vortran HEART) was developed. The goal of this study was to determine actual drug delivery of the HEART and conventional SVNs for both adult and pediatric breathing patterns.

DESIGN

Output studies were conducted on comparable samples of CIS-US AeroTech II and Hospitak PowerMist SVNs and Vortran HEART large-volume continuous nebulizers. To duplicate clinical aerosol delivery via an aerosol mask, drug particles were inhaled through the mouth of a model of a human face for two test breathing patterns (adult = tidal volume (Vt) of 500 mL, 20 breaths/min, duty cycle of 40%; pediatric = VT of 100 mL, 35 breaths/min, duty cycle of 40%), generated by a ventilator. Radiolabeled particles of saline solution, confirmed to behave identically to albuterol, were collected on absolute filters at the mouth of the face to measure the actual mass of albuterol particles delivered to the airway opening.

RESULTS

The AeroTech II and PowerMist SVNs delivered 5.14 and 3.74 mg/h, respectively, for the adult breathing pattern and 2.97 and 2.48 mg/h, respectively, for the pediatric breathing pattern. Drug delivery rates of the HEART were a function of drug concentration and ranged from 0.87 to 3.48 mg/h for the adult breathing pattern. For the pediatric breathing pattern, drug delivery rate was a function of drug concentration and inspired minute ventilation and ranged from 0.41 to 1.83 mg/h.

CONCLUSION

Our data demonstrate that drug delivery to the patient, expressed as inhaled mass over time, is similar for continuous nebulization (HEART system) and intermittently filled SVNs. In addition, for all nebulizers, the influence of the pediatric breathing pattern needs to be considered. Continuous nebulization permits the redistribution of health-care personnel and may reduce the costs of therapy.

Measuring nebulizer output. Aerosol production vs gravimetric analysis

STUDY OBJECTIVES

The function of jet nebulizers has been measured traditionally by gravimetric methods, i.e., by weighing nebulizers before and after nebulization. Newer techniques measure aerosol output directly by analyzing aerosolized drug or tracer, i.e., radioactive 99mTc. Because of evaporation, the equivalence of these methods is uncertain. The aim of this study was to determine if the gravimetric method is an accurate measure of aerosol production under different conditions of aerosol generation (i.e., nebulizer type, flow rate, pressure, volume fill, and concentration of solution used to nebulize a drug).

METHODS

In the first phase of the study, we measured the aerosol output of nine commercially available jet nebulizers (AvaNeb; Up-Draft-Hudson RCI; Cirrus-Intersurgical Inc; DeVilbiss 646-DeVilbiss; Powermist-Hospitak, Inc; Respirgard II-Marquest Medical Products; Seamless-Seamless/Dart Respiratory; Salter; Salter Labs; Airlife-Baxter Health Care) run under commonly used conditions (2.5 mL volume fill, 2.0 mL normal saline solvent, 0.5 mL albuterol, flow of 6 L/min, and pressures averaging 15.0 +/- 2.3 [mean +/- SD] pounds per square inch [on the] gauge [psig] provided by a DeVilbiss PulmoAide compressor) with simultaneously measured gravimetrics and filtered radioactivity. Each nebulizer was run to dryness with data acquired every 2 min. The change in the weight of the nebulizer and radioactivity captured on the filter were expressed as percentages of the total in the nebulizer solution. In the second phase of the study, the experiments were repeated using the same nebulizers with a volume fill of 5 mL (diluted to half normal saline solution plus albuterol), flow of 10 L/min, and pressures of 35.6 +/- 8.8 psig.

RESULTS

The cumulative (sum of all 2-min runs) weight loss for each individual nebulizer ranged from 25.00 to 64.55% and cumulative aerosol captured varied from 12.63 to 38.76%. While different, the weight loss and aerosol captured were closely correlated (y = -0.62 + 0.62x; r = 0.961, p < 0.0001). Changing volume fill and concentration of solvent did not affect this correlation (p = 0.921 and 0.373, respectively). However, changing flow from 6 L/min to 10 L/min significantly (p = 0.02) affected the relationship (y = -3.80 + 0.83x; r = 0.969, p < 0.001).

CONCLUSIONS

When compared with direct methods such as filtering generated particles, the gravimetric method of assessing nebulizer function overestimates aerosol output by 1.8 +/- 0.18 times, presumably because of the loss of solvent during nebulization. However, the relationship between methods is predictable and appears unaffected by changing the type of nebulizer, volume fill, and concentration of solvent. Changes in nebulizer flow and pressure significantly affected the correlation. Gravimetric methods can be used as simple and convenient screening techniques for comparing jet nebulizers under a wide range of experimental conditions.

Silent laryngopharyngeal sensory deficits after stroke

Dysphagia and aspiration are two devastating sequelae of stroke. Recent work has shown that laryngopharyngeal (LP) sensory deficits are associated with aspiration in stroke patients with dysphagia. The phenomenon of silent LP sensory deficits, where the patient exhibits no subjective or objective evidence of dysphagia, yet has an LP sensory deficit, has not been previously described. The aim of this study was to evaluate the sensory capacity of the laryngopharynx in stroke patients who had no subjective or objective complaints of dysphagia. We determined the sensory threshold in the laryngopharynx using air pulse stimulation of the mucosa of the pyriform sinus and aryepiglottic fold. Eighteen stroke patients (mean age 65.6 +/- 11.5 years) and 18 age-matched controls were prospectively evaluated. Normal thresholds were defined as < 4.0 mm Hg air pulse pressure (APP). Deficits were defined as either a moderate impairment in sensory discrimination thresholds (4.0 to 6.0 mm Hg APP) or a severe sensory impairment (> 6.0 mm Hg APP). Stroke patients were followed up for 1 year to determine the incidence of aspiration pneumonia (AP) as verified by chest radiography. In 11 of the stroke patients studied, either unilateral (n = 6) or bilateral (n = 5) severe sensory deficits were identified. The elevations in sensory discrimination thresholds were significantly greater than those in age-matched controls (7.1 +/- 0.6 mm Hg APP versus 2.5 mm Hg APP; p < .01, Wilcoxon score). Among patients with unilateral deficits, sensory thresholds were severely elevated in all cases on the affected side compared with the unaffected side (p < .01, Wilcoxon score). Moreover, the sensory thresholds of the unaffected side were not significantly different from those of age-matched controls. Aspiration pneumonia did not occur in the patients with normal LP sensation or in the patients with unilateral severe LP sensory deficits. However, in the 5 patients with bilateral, severe LP sensory deficits, 2 developed AP, both within 3 months of their LP sensory test. The results of this study showed, for the first time, that stroke patients without subjective or objective clinical evidence of dysphagia could have silent LP sensory deficits. These impairments could contribute to the development of AP following stroke. The findings in this study suggest that LP sensory discrimination threshold testing should not be restricted only to patients with clinical dysphagia.

Polysomnographic studies in patients referred for ECT: pre-ECT studies

Forty-one patients referred for electroconvulsive therapy (ECT) were evaluated with a standardized clinical protocol and had polysomnographic studies performed pre-ECT after 10 or more days drug free. Clinical evaluations were performed by blind investigators and included the Research Diagnostic Criteria and the Hamilton Rating Scale for Depression (HRSD). Patients were categorized according to the clinical response. Thirty patients (73%) reached a post-ECT HRSD < or = 10, whereas 21 of them (51.2%) reached a post-ECT HRSD score < or = 6. Sleep-onset rapid eye movement (SOREM) periods were present in 27 (66%) of the patients. Few polysomnographic variables differentiated between excellent responders and patients with residual symptoms. Older patients had significantly more disrupted polysomnographic study parameters. Although present in a significant proportion of patients, baseline SOREM was not a factor in outcome.

Biological predictors of suicidality in schizophrenia

The objective of this study was to determine whether polysomnographic rapid eye movement (REM) sleep abnormalities and cortisol response to the dexamethasone suppression test (DST) differentiate between schizophrenic patients with and without a history of suicidal behaviour. We assessed a sample of 96 schizophrenic in-patients at the end of a 2-week medication-free period with the DST, polysomnography, and an extensive clinical assessment battery. Patients exhibiting suicidal behaviour were significantly more likely to have increased total REM time and increased total REM activity. We found no significant relationship between suicidal behaviour and DST non-suppression. This study confirms a previous finding suggesting an association between REM sleep abnormalities and suicidal behaviour in schizophrenia. It is postulated that this observed association may be related to serotonergic dysfunction in schizophrenia.

Biological predictors of 1-year outcome in schizophrenia in males and females

This paper describes a prospective study designed to ascertain the predictive value of biological factors associated with schizophrenia in males and females. In a sample of 59 medication-free schizophrenic inpatients (41 males; 18 females), we assessed the correlation of four factors--rapid eye movement (REM) sleep latency, delta (slow-wave) sleep, dexamethasone suppression test (DST) cortisol levels, and ventricle-brain ratio (VBR)--with several dimensions of outcome at 1-year post-discharge. In the total sample, shorter REM latency was associated with poor outcome on all dimensions measured: rehospitalization, employment, social activity, symptomatology, and global functioning. However, none of the other biological factors were associated with any measure of outcome. The predictive value of REM latency appeared to be gender-specific; in general, the relationships between reduced REM latency and poor outcome were consistently noted in females, but were not significant in males. These results suggest that a common, possibly gender-related, pathophysiological mechanism might underlie both abnormal REM latency and poor outcome. The findings underscore the importance of considering gender differences in studies of schizophrenia.

VBR in schizophrenia: relationship to family history of psychosis and season of birth

Ventricular enlargement has been consistently demonstrated in schizophrenia using both CT and MRI. Despite this, the structural changes that underlie increased ventricle-brain ratio (VBR) and its relationship to environmental factors (intrauterine viral exposure, obstetric complications, etc.) and family history of schizophrenia remain poorly defined. Increased VBR has been shown in some studies to correlate with an absence of family history of schizophrenia and with Winter-Spring birth. In an attempt to obtain a clearer picture of the contribution of environmental and genetic factors to VBR, we studied 54 patients with DSM III-R schizophrenia. VBR was determined from head CT scans via computerized planimetry. Family history of psychosis and non-psychotic mood disorder was determined with the family informant method. Season of birth was encoded in several ways, including season, trimester and dichotomously. Patients without a family history of psychosis had significantly larger VBR than patients with such a history; family history of mood disorder was not related to VBR. Season of birth was not predictive of VBR. Family history of psychosis and season of birth were not related to each other. These results are in line with prior work demonstrating an association between increased VBR and sporadic (non-familial) schizophrenia. We did not find a relationship between VBR and season of birth, which suggests that risk of perinatal viral exposure and other seasonal environmental factors may not account for the ventricular enlargement in non-familial schizophrenia observed in our sample.

Facilitation and interference of selective attention in schizophrenia

Theories of attentional impairment in schizophrenia predict excessive interference in selective attention tasks, such as the Stroop task, where subjects must name the color of words which spell colors different than the to-be-named-color. However, a recent study actually found greater facilitation, i.e. improved color-naming time when the color-word agrees with the to-be-named color, and near-normal interference in schizophrenic patients when compared to normal controls. To evaluate these findings, we studied 12 schizophrenic patients (10 on neuroleptics), and 12 age- and gender-matched, healthy subjects in a trial-by-trial Stroop task. The patients exhibited significantly greater facilitation on the Stroop task compared to the normal controls (81 and 12 ms, respectively). Interference effects were not significantly greater for the schizophrenic patients. These findings suggest a need for more work to investigate why schizophrenic patients appear to benefit from the facilitation condition more than normal controls do.

Prevalence and patterns of smoking in Delhi: cross sectional study

OBJECTIVE

To determine the prevalence and predictors of smoking in urban India.

DESIGN

Cross sectional.

SETTING

Delhi, urban India, 1985-6.

SUBJECTS

Random sample of 13,558 men and women aged 25-64 years.

MAIN OUTCOME MEASURES

Smoking prevalence; subjects who were currently smoking and who had smoked > or = 100 cigarettes or beedis or chuttas in their lifetime were defined as smokers.

RESULTS

45% (95% confidence interval 43.8 to 46.2) of men and 7% (6.4 to 7.6) of women were smokers. Education was the strongest predictor of smoking, and men with no education were 1.8 (1.5 to 2.0) times more likely to be smokers than those with college education, and women with no education were 3.7 (2.9 to 4.8) times more likely. Among smokers, 52.6% of men and 4.9% of women smoked only cigarettes while the others also smoked beedi or chutta. Compared with cigarette smokers, people smoking beedi or chutta were more likely to be older and married; have lower education, manual occupations, incomes, and body mass index; and not drink alcohol or take part in leisure exercise.

CONCLUSION

There are two subpopulations of smokers in urban India, and the prevention strategy required for each may be different. The educated, white collar cigarette smoker in India might respond to measures that make non-smoking fashionable, while the less educated, low income people who smoke beedi or chutta may need strategies aimed at socioeconomic improvement.

Spatial relationships of neuroanatomic landmarks in schizophrenia

Two new morphometric techniques, landmark-based shape analysis and landmark-based image averaging, were applied to magnetic resonance images (MRIs) to investigate the sites and extent of structural neuropathology in schizophrenia. These analyses allow the identification of averaged anatomy through joint registration on multiple landmarks simultaneously. MRI scans obtained in the midsagittal plane were compared between 14 patients with schizophrenia and 14 normal subjects. The relation between averaged landmark configuration in the two groups was visualized as a deformation. There were no large-scale shape abnormalities noted, although the patients had significantly smaller brains. The data suggest that the neuroanatomic abnormality associated with schizophrenia, in the midsagittal plane, is circumscribed (focal), involving primarily the region of the posterior corpus callosum, upper brainstem, and quadrigeminal cistern. Also, the thickness of the corpus callosum is reduced all along its length. The findings are consistent with prior studies suggesting involvement in schizophrenia of the cerebellum, the corpus callosum and, possibly, the limbic structures contributing to the corpus callosum. The methods of image averaging and shape analysis used in this study complement the 'region of interest' method of investigating morphometric abnormalities by characterizing the precise locations and spatial relationships among relevant structural brain abnormalities in schizophrenia.

ECT in genetically confirmed Huntington's disease

The authors report successful ECT treatment of a severely depressed man with genetically confirmed Huntington's disease. He responded well to treatment and showed no abnormal movements or worsening in his cognitive status.