Post-Traumatic Stress Disorder after Subarachnoid Hemorrhage: A Systematic Review

Background

Post-traumatic stress disorder (PTSD) frequently follows neurological disorders such as non-traumatic subarachnoid hemorrhage (SAH) and has debilitating consequences.

Objective

The aim of this systematic review was the critical appraisal of the literature on the frequency, severity, and temporal progression of PTSD in patients with SAH, the etiology of PTSD, and its effect on patients' quality of life (QoL).

Material and Methods

Studies were obtained from three databases: PubMed EMBASE, PsycINFO, and Ovid Nursing. The inclusion criteria were English-language studies on adults (defined as at least 18 years of age) in which ≥10 of the participants received a diagnosis of PTSD following SAH. Applying these criteria, 17 studies (N = 1,381) were included.

Results

Between 1% and 74% of the participants in each study had PTSD, with a weighted average of 36.6% across all studies. Post-SAH PTSD showed significant correlations with premorbid psychiatric disorders, neuroticism, and maladaptive coping styles. The risk of PTSD was also higher in participants with comorbid depression and anxiety. Stress related to post-ictal events and fear of recurrence were associated with PTSD. However, the risk of PTSD was lower in participants with effective social support networks. The participants' QoL was negatively affected by PTSD.

Conclusions

This review highlights the high occurrence of PTSD in SAH patients. The temporal progression and chronicity of post-SAH PTSD warrant further research, as do its neuroanatomical and neurochemical correlates. We call for more randomized controlled trials investigating these aspects.

[Effects of caloric restriction and rope-skipping exercise on cardiometabolic risk factors in overweight or obese college students]

Objective: To explore the effect of three interventions including caloric restriction, rope-skipping exercise and caloric restriction combined with rope-skipping exercise on cardiometabolic risk factors in overweight or obese college students. Methods: This study was a pilot randomized controlled trial. Overweight or obese students who met the inclusion criteria were recruited at Sun Yat-sen University in September 2019 and were randomly divided into four groups: caloric restriction group (CR), rope-skipping group (RS), combined group (CR-RS) and control group (CT). The intervention in each group lasted 8 weeks, specifically: the daily energy intake of CR was 100% to 110% of the basal metabolic energy; RS was instructed to rope three times a week, and CR-RS combined caloric restriction with rope-skipping. At the baseline and end of 8-week intervention, basic information, anthropometric indicators and fasting vein blood of students were collected. Paired t test and Wilcoxon paired-samples signed rank test were used for comparison before and after intervention, and analysis of covariance was used for comparison between groups after intervention. Results: A total of 29 students completed the trial and were included in the final analysis (7, 9, 7 and 6 students in CR, RS, CR-RS and CT, respectively). The mean age of students were (19.00±1.00) years, including 11 males and 18 females. The baseline characteristics of four groups were comparable. After 8 weeks of intervention, compared with CT, there was an increase in the body fat percentage and fat mass index in CR and CR-RS (P<0.05). Insulin level decreased in CR-RS (P<0.05). Systolic blood pressure in CR and diastolic blood pressure in CR-RS were higher (P<0.05). Compared with baseline, fat mass index decreased in CR (P<0.05), while body weight, BMI, and fat mass index decreased in CR-RS (P<0.05). Conclusion: It is suggested that the caloric restriction alone and calorie restriction combined with rope-skipping exercise can benefit overweight or obese college students with cardiometabolic risk factors.

Computer-Assisted Cognitive Training for Patients with Severe Mental Illness: a Retrospective Study

OBJECTIVES

To investigate the effectiveness of eight 45-minute sessions of computer-assisted cognitive training programme (CCTP) on improving the cognitive and functional performance of patients with Severe Mental Illness (SMI).

METHODS

Medical records of 16 women and 13 men aged 26 to 62 (mean, 46.34) years who participated a CCTP were reviewed. The CCTP lasted a total of 6 hours in eight sessions over 8 weeks and comprised a series of mobile applications customised to patients' specific impaired cognitive domains. Pre- and post-test performance of cognition and functioning were assessed using the Montreal Cognitive Assessment Hong Kong version (HK-MoCA) and the Brief Assessment of Prospective Memory (BAPM), respectively.

RESULTS

After the CCTP, the mean HK-MoCA score increased significantly (23.62 ± 5.34 vs 25.48 ± 3.75, d = 0.403, p = 0.001), with a significant increase in delayed recall (3.14 ± 1.75 vs 3.93 ± 1.44, d = 0.493, p = 0.003), and the mean BAPM score decreased significantly (1.44 ± 0.47 vs 1.26 ± 0.23, d = 0.486, p = 0.012). The improvement was greater in participants with primary-level education than in participants with secondary- or tertiary-level education in terms of the HK-MoCA score (3.83 ± 3.06 vs 1.35 ± 2.12, d = 0.942, p = 0.046) and the BAPM scores (-0.49 ± 0.43 vs -0.10 ± 0.29, d = 1.063, p = 0.035).

CONCLUSION

Our shortened CCTP effectively enhanced the cognitive performance and daily functioning of patients with SMI. Verbal episodic memory showed the most improvement. The improvement was greater in those with primary-level education than in those with secondary- or tertiary-level education.

Effect of traction on wrist joint space and cartilage visibility with and without MR arthrography

OBJECTIVE

To compare the effect of traction during non-arthrographic and arthrographic MR examination of the wrist with regard to joint space width, joint fluid dispersion and cartilage surface visibility.

METHODS

Prospective 3-T MRI study of 100 wrists in 96 patients. The first 50 wrists underwent MR arthrography first without traction and then with traction. The following 50 wrists underwent standard MR first without traction and then with traction. On these examinations, two radiologists independently measured (i) joint space width, semi-quantitatively graded (ii) joint fluid dispersion between opposing cartilage surfaces and (iii) articular cartilage surface visibility. The three parameters were compared between the two groups.

RESULTS

Traction led to an increase in joint space width at nearly all joints in all patients (p < 0.05), although more so in the arthrography (∆ = 0.08-0.79 mm, all p < 0.05) than in the non-arthrography (∆ = 0.001-0.61 mm, all p < 0.05) group. Joint fluid dispersion and cartilage surface visibility improved after traction in nearly all joints (p < 0.05) in all patients and more so in the arthographic than in the non-arthrography group.

CONCLUSION

Traction did significantly improve cartilage surface visibility for standard MRI of the wrist although the effect was not as great as that seen with MR arthography or MR arthrography with traction. Advances in knowledge: This is the first study to show the beneficial effect of traction during standard non-arthrography MRI of the wrist and compare the effect of traction between non-arthrographic and arthrographic MRI of the wrist.

Pontine microbleeds and depression in stroke

OBJECTIVES

Depression is the most common affective disorder following stroke yet the neuroanatomical model of poststroke depression (PSD) remains unclear. This study examined the association between PSD and cerebral microbleeds (CMBs) and hypothesized that CMBs in specific regions would be associated with PSD.

METHODS

Of the 4766 patients with first ever or recurrent acute ischemic stroke admitted to the Acute Stroke Unit of the Prince of Wales Hospital between June 2004 and October 2010, 229 met the entry criteria and formed the study sample. Patients with a Geriatric Depression Scale score of 7 or above were classified as having PSD. The presence and location of CMBs were evaluated with magnetic resonance imaging.

RESULTS

Compared to the non-PSD group, patients with PSD were more likely to have pontine CMBs (32.0% vs 18.2%; P = .019). The presence of pontine CMBs remained an independent predictor of PSD in the multivariate analysis, with an odds ratio of 2.2 (P = .016).

CONCLUSION

The results suggest that pontine CMBs are associated with a higher risk of developing PSD.

Relationship between cognitive impairment and depressive symptoms in current ketamine users

OBJECTIVE

Both cognitive impairment and depressive symptoms have been reported in ketamine users. However, no previous study has examined the relationship between them. This study aimed to examine cognitive functions and depressive symptoms and their relationship in young ketamine users in Hong Kong.

METHOD

Fifty-one current ketamine users, 49 ex-ketamine users, and 100 healthy controls were recruited from counseling and youth centers in Hong Kong in this cross-sectional study. Cognitive assessment included mental and motor speed; working, verbal, and visual memory; and executive functions. Depressive symptoms were measured using the Beck Depression Inventory. One-way analyses of covariance (ANCOVA) and chi-square tests were used to analyze participants' demographic data, patterns of drug use, Beck Depression Inventory score, and performance in a cognitive battery. Cognitive functions were adjusted for age, gender, and education using ANCOVA. Correlations between the Beck Depression Inventory score and cognitive functions were examined using Pearson's correlation coefficient.

RESULTS

Cognitive impairment was found only in current ketamine users in the domains of mental and motor speed (p < .001), visual and verbal memory (p < .001), and executive functions (p < .001). Depressive symptoms were also more frequently found in current ketamine users (p < .001). Correlations between depressive symptoms and certain cognitive scores were statistically significant but modest.

CONCLUSIONS

Current ketamine use is associated with cognitive impairment. Illicit substance treatment and rehabilitation services should pay attention to ketamine's cognitive effects and motivate their clients to quit using ketamine and stay abstinent.

Location of infarcts and apathy in ischemic stroke

BACKGROUND

Apathy is common in stroke survivors. Unlike poststroke depression, apathy after stroke has not been extensively investigated and the significance of the location of infarcts in the development of apathy following a stroke is unknown. This study examined the association between poststroke apathy (PSA) and the location of infarcts.

METHODS

A cohort of 185 patients with acute ischemic stroke admitted to the Stroke Unit of a university-affiliated regional hospital in Hong Kong was recruited. Three months after the index stroke, a psychiatrist administered the Apathy Evaluation Scale (AES). PSA was defined as an AES score of 37 or above. The presence and location of infarcts were evaluated with magnetic resonance imaging.

RESULTS

Altogether 185 patients met the entry criteria and formed the study sample; 20 (10.8%) had PSA. PSA patients were older and had higher stroke severity and more depressive symptoms. The PSA group also had lower levels of physical and cognitive functioning. Compared with the non-PSA group, PSA patients were more likely to have acute pontine infarcts (35.0% vs. 11.5%; p = 0.011). They had a higher mean number (0.5 ± 0.7 vs. 0.1 ± 0.3; p = 0.003) and larger volume (0.6 ± 1.4 vs. 0.1 ± 0.3 ml; p = 0.002) of acute pontine infarcts. Six variables were entered into the predictive regression model: age, the presence, number and volume of acute pontine infarcts, the number of old infarcts and periventricular white matter hyperintensities scores. The volume of infarcts remained an independent predictor of PSA in the multivariate analysis, with an odds ratio of 3.9 (p = 0.007). The Geriatric Depression Scale, National Institutes of Health Stroke Scale, Barthel Index and Mini-Mental State Examination scores were also entered into the subsequent associative regression model; the volume of acute pontine infarcts remained a significant predictor (odds ratio = 3.8).

CONCLUSIONS

This is the first report of an association between pontine infarcts and the risk of PSA. The results suggest that pontine infarcts may play a role in the development of PSA. The importance of acute pontine infarcts in the pathogenesis of PSA warrants further investigation.

Serotonin receptor 2C gene polymorphism associated with post-stroke depression in Chinese patients

The serotonin receptor 2C (HTR2C) gene has been shown to play a pivotal role in major depression. We examined the association between post-stroke depression (PSD) and polymorphism in HTR2C. A cohort of 223 patients with acute lacunar stroke admitted to the stroke unit of a university-affiliated regional hospital in Hong Kong was recruited. Three months after the onset of the index stroke, a research assistant administered the locally validated 15-item Geriatric Depression Scale. PSD was defined as a geriatric depression scale score of 7 or above. Possible confounding factors, including previous history of stroke, severity of stroke, level of social support, and recent life events, were investigated. All patients were genotyped for polymorphisms of HTR2C. Separate analyses were performed for males and females. Sixty-one patients were found to have PSD. There were significant associations between the HTR2C gene and PSD status in the male patients, but not in the female ones. After adjusting for possible confounders, the rs12837651 T allele (odds ratio = 4.020) and the rs2192371 G allele (odds ratio = 2.866) were found to be significantly associated with PSD in males. Genetic variation in HTR2C receptors appears to be involved in the pathogenesis of PSD in Chinese males.

Clinical characteristics of cough mixture abusers referred to three substance abuse clinics in Hong Kong: a retrospective study

OBJECTIVES. Cough mixture is the third most commonly abused substance in patients attending the Prince of Wales Hospital Substance Abuse Clinic. The content of the local cough mixture is not well researched. Paranoid psychosis manifesting as persecutory delusions and derogatory hallucination, as well as mood symptoms, is common in these patients. The natural history and outcome of such psychoses associated with cough mixture abuse are not well known. This study aimed to address these questions. METHODS. This was a retrospective study of cough mixture abuse in Hong Kong. Case records of cough mixture abusers currently receiving treatment at the 3 substance abuse clinics at the Prince of Wales Hospital, Alice Ho Miu Ling Nethersole Hospital, and the North District Hospital were retrieved for data collection. The patients' demographic data, duration and intake pattern of cough mixture, and use of any other drugs were documented. The presenting psychopathology, first urine toxicology results, diagnosis, treatment, number of hospitalizations, and course of the illness were also recorded. RESULTS. A total of 63 patients with the diagnosis of cough mixture abuse were identified in the database; 89% were male. The mean +/- SD age of the patients was 34.4 +/- 6.2 years; 67% were single and 83% were unemployed. The mean +/- SD age of onset of cough mixture abuse was 20 +/- 5 years. Psychiatric symptoms developed a mean +/- SD of 7.6 +/- 6.0 years after onset of abuse. According to the ICD-10 Mental and Behavioural Disorders criteria, the top psychiatric diagnoses were substance-induced psychotic disorder (67%), schizophrenia (19%), depressive disorder (11%), and dysthymia (10%). The most common ingredients in the urine sample at first presentation were promethazine (75%), pseudoephedrine (67%), codeine (60%), ephedrine (57%), zopiclone (17%), and hydrocodone (16%). Additionally, 16% of patients were in the priority follow-up group. The mean +/- SD follow-up period was 6.2 +/- 7.1 years during which there were 3.2 +/- 3.7 episodes of hospitalizations, with a mean +/- SD length of stay in each admission of 25.0 +/- 40.9 days. CONCLUSIONS. Promethazine, ephedrine, pseudoephedrine, codeine, and hydrocodone are the most common ingredients of cough mixture abused in this locality. Psychotic disorders are the most frequent psychiatric diagnosis associated with cough mixture abuse.

Poststroke fatigue is associated with caudate infarcts

OBJECTIVE

The caudate nucleus may be involved in the pathogenesis of the fatigue observed in neurological disorders. However, the significance of caudate lesions in poststroke fatigue (PSF) is unknown. This study examined the association between caudate infarcts and PSF.

METHODS

Five hundred Chinese patients with acute ischemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong participated in the study. All participants were assessed for PSF with the Fatigue Severity Scale (FSS) three months after their index stroke. PSF was defined as a mean FSS score of 4.0 or more. Physical functioning and depressive symptoms were measured by the Barthel Index (BI) and the Geriatric Depression Scale (GDS).

RESULTS

One hundred and twenty-five (25.0%) of the patients had PSF. Compared to the non-fatigue group, the PSF patients were more likely to be women and had hyperlipidemia, lower BI and higher GDS scores. Caudate (8.0% versus 1.3%, p=0.001) and putamen (19.2% versus 12.0%, p=0.043) acute infarcts were more common in the PSF group, whereas pons infarcts (13.6% versus 22.2%, p=0.038) were less common. Acute caudate infarcts remained an independent predictor of PSF in the multivariate analysis, with an odds ratio of 6.4.

CONCLUSIONS

The results suggest that patients with PSF are more likely to have caudate infarcts.

Predictors of the depressive symptomatology of the family caregivers of Chinese stroke patients in Hong Kong

The aim of this cross-sectional study was to determine the socio-demographic and clinical factors associated with depressive symptoms in the family caregivers of Hong Kong Chinese stroke patients. One hundred and twenty-three patients at a stroke clinic and their family caregivers formed the study sample. The depressive symptoms of both the patients and their family caregivers were rated with the Chinese version of the 15-item Geriatric Depression Scale (GDS). Participants' socio-demographic data and clinical characteristics served as the independent variables in relation to the caregivers' GDS scores. Patients' and caregivers' somatic and psychological conditions were measured with 10 scales. In univariate analysis, caregivers' GDS scores were significantly correlated with certain of their characteristics [Modified Life Event Scale (MLES), Cumulative Illness Rating Scale (CIRS) and Lubben Social Network Scale (LSNS) scores, sex and being a housewife] and those of the patients (GDS score and being a housewife). Multiple regression analysis showed caregivers' MLES and CIRS scores and patients' GDS scores to be independent correlates of caregivers' GDS scores. Adverse events encountered by caregivers in the past 6 months, their current health problems and patients' depressive symptoms were found to be the principal factors associated with caregivers' depressive symptoms.

A randomized, controlled clinical trial: the effect of mindfulness-based cognitive therapy on generalized anxiety disorder among Chinese community patients: protocol for a randomized trial

BACKGROUND

Research suggests that an eight-week Mindfulness-Based Cognitive Therapy (MBCT) program may be effective in the treatment of generalized anxiety disorders. Our objective is to compare the clinical effectiveness of the MBCT program with a psycho-education programme and usual care in reducing anxiety symptoms in people suffering from generalized anxiety disorder.

METHODS

A three armed randomized, controlled clinical trial including 9-month post-treatment follow-up is proposed. Participants screened positive using the Structure Clinical Interview for DSM-IV (SCID) for general anxiety disorder will be recruited from community-based clinics. 228 participants will be randomly allocated to the MBCT program plus usual care, psycho-education program plus usual care or the usual care group. Validated Chinese version of instruments measuring anxiety and worry symptoms, depression, quality of life and health service utilization will be used. Our primary end point is the change of anxiety and worry score (Beck Anxiety Inventory and Penn State Worry Scale) from baseline to the end of intervention. For primary analyses, treatment outcomes will be assessed by ANCOVA, with change in anxiety score as the baseline variable, while the baseline anxiety score and other baseline characteristics that significantly differ between groups will serve as covariates.

CONCLUSIONS

This is a first randomized controlled trial that compare the effectiveness of MBCT with an active control, findings will advance current knowledge in the management of GAD and the way that group intervention can be delivered and inform future research. Unique Trail Number (assigned by Centre for Clinical Trails, Clinical Trials registry, The Chinese University of Hong Kong): CUHK_CCT00267.

Cerebral microbleeds and depression in lacunar stroke

BACKGROUND AND PURPOSE

Cerebral microbleeds (CMB) are common in stroke survivors and the community-dwelling elderly. The clinical significance of CMB in the development of depression after a stroke is unknown. This study examined the association between poststroke depression (PSD) and CMB.

METHODS

A cohort of 235 patients with acute lacunar stroke admitted to the stroke unit of a university-affiliated regional hospital in Hong Kong was recruited. Three months after the onset of the index stroke, a research assistant administered the locally validated 15-item Geriatric Depression Scale. PSD was defined as a Genetic Depression Scale score of ≥7. The presence and location of CMB were evaluated with MRI.

RESULTS

In comparison with the non-PSD group, PSD patients were more likely to have lobar CMB (33.3% versus 19.9%; P=0.022). Lobar CMB remained an independent predictor of PSD in the multivariate analysis, with an odds ratio of 2.08 (P=0.032).

CONCLUSIONS

The results suggest that lobar CMB may play a role in the development of PSD. The importance of CMB in the pathogenesis of depression in stroke survivors and the general elderly population warrants further investigation.

Impulse control disorders in Chinese Parkinson's disease patients: the effect of ergot derived dopamine agonist

OBJECTIVE

We studied the prevalence and related risk factors of impulse control disorders in Chinese Parkinson's disease patients.

METHOD

We screened all non-demented Parkinson's disease patients attending our Parkinson's disease clinic from August 2009 to March 2010. The clinical characteristics of patients with impulse control disorders and those without were compared.

RESULTS

Of the 213 PD subjects screened, 15 (7.0%) with impulse control disorders were identified. Fourteen of these subjects were on both a dopamine agonist and Levodopa, and one was on Levodopa alone. Of the fourteen subjects on both a dopamine agonist and Levodopa, eleven were on bromocriptine and Levodopa; 10.5% of the subjects exposed to bromocriptine had impulse control disorder. Upon multivariate analysis, dose of dopamine agonist used, young age at onset of Parkinson's disease and a history of anxiety or depression were independent predictors for developing impulse control disorders.

CONCLUSIONS

7% of our Chinese PD subjects had impulse control disorders. When young Parkinson's disease patients with a history of anxiety or depression are treated with high dose of DA, they are at risk of developing impulse control disorders.

Referral patterns and clinical characteristics of subjects referred to substance abuse clinic of a regional hospital in Hong Kong

OBJECTIVES

To examine the clinical characteristics of subjects referred to the Substance Abuse Clinic of the Prince of Wales Hospital between 1 January 2007 and 31 December 2009 in Hong Kong.

METHODS

A chart review of 131 subjects referred to the Substance Abuse Clinic during the study period was carried out. Psychiatric diagnoses were made by a psychiatrist, according to the 10th edition of the International Classification of Diseases.

RESULTS

Social workers were increasingly a main source of referrals, accounting for 34% of referrals during the entire study period (and 43% in 2009). Another important referral source was the Hospital Authority system in Hong Kong, which accounted for 38% of referrals over the 3-year study period. Ketamine, methamphetamine, and cough mixtures were the most common drugs of primary misuse, the proportion of users being 34%, 24% and 12%, respectively. In these referals, the most common psychiatric diagnosis was substance-induced psychotic disorder, followed by depressive disorder, made in 44% and 22% of the subjects, respectively.

CONCLUSIONS

Among Hong Kong substance abusers, psychotic and depressive disorders are common, and ketamine is the most commonly misused drug.

Cerebral microbleeds and symptom severity of post-stroke depression: a magnetic resonance imaging study

BACKGROUND

Cerebral microbleeds (CMBs) are common in stroke survivors, although their clinical significance in the development of psychiatric conditions following stroke remains unknown. This study examines the association between post-stroke depression (PSD) symptom severity and CMBs.

METHODS

Amongst the 4088 patients with acute ischemic stroke who had been admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong, between December 2004 and May 2009, 994 patients were recruited. A psychiatrist administered the Structural Clinical Interview for DSM-IV to all 994 patients and made a diagnosis of PSD three months after the index stroke. PSD symptom severity was assessed with the 15-item Geriatric Depression Scale (GDS). Seventy-eight patients were found to have PSD. The presence and location of CMBs were evaluated with magnetic resonance imaging (MRI).

RESULTS

Seventy-eight patients (7.8%) had PSD. CMBs were identified in 20 PSD patients. Relative to the no-CMB group, the mean GDS score of patients with lobar CMBs was significantly higher (12.6±2.6 versus 10.4±2.5, p=0.01 after adjusting for age, sex, global cognitive functions, neurological deficits and white matter hyperintensities).

LIMITATIONS

Patients with more severe stroke, those who died before the three-month follow-up and those who became depressed later were excluded, as were those unable to give their consent due to dementia or aphasia. These selection biases may limit the generalizability of the findings.

CONCLUSIONS

The results suggest that lobar CMBs may contribute to PSD symptom severity. The importance of CMBs in the pathogenesis of other psychiatric disorders in stroke survivors and other patient populations warrants further investigation.

Psychiatric morbidity at a female residential drug treatment centre in Hong Kong

OBJECTIVE

To describe the psychiatric co-morbidity of female psychotropic substance abusers treated at a residential treatment centre.

METHODS

Subjects were recruited from a female residential substance abuse treatment centre in Hong Kong--the Society for the Aid and Rehabilitation for Drug Abusers. Demographic data and substance abuse habits were recorded. Psychiatric diagnoses were established with the Structured Clinical Interview for the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders.

RESULTS

Of the 42 residents, 32 agreed to participate in the study. All of whom completed the questionnaire and the Structured Clinical Interview for the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders. Concerning substance abuse, 84%, 38%, and 34% of the subjects were dependent on ketamine, methamphetamine and cocaine, respectively. The most common lifetime psychiatric diagnosis was substance-induced mood disorder (47%), followed by substance-induced psychotic disorder (16%).

CONCLUSIONS

Psychiatric disorders complicate heavy substance abuse in the majority of female patients. Regular screening of this population with standardised diagnostic instruments for psychiatric comorbidity is clearly warranted.

Cortical and frontal atrophy are associated with cognitive impairment in age-related confluent white-matter lesion

OBJECTIVE

Although age-related confluent white-matter lesion (WML) is an important substrate for cognitive impairment, the mechanisms whereby WML induces cognitive impairment are uncertain. The authors investigated cognitive predictors in patients with confluent WML.

METHODS

Among 100 patients with ischaemic stroke with confluent WML on MRI, the authors assessed executive function and global cognition by the Mattis Dementia Rating Scale--Initiation/Perseveration Subscale (MDRS I/P) and Mini-Mental State Examination (MMSE), respectively. All volumetric measures were corrected for intracranial volume. The authors investigated the association between basic demography, vascular risk factors, APOE status, WML volume, infarct measures (volume, number, location), microbleed number, atrophy measures (global, central, regional) and cognitive performance. The authors also performed Pittsburgh Compound B (PIB) imaging among seven cognitive impaired patients with stroke.

RESULTS

WML was no longer related to cognitive performance after adding atrophy into regression equations. Multivariate regression models showed that cortical grey matter volume independently accounted for performance on both the MDRS I/P (β=0.241, p=0.045) and MMSE (β=0.243, p=0.032). Models examining frontal subregions revealed that volumes of both left (β=0.424, p<0.001) and right (β=0.219, p=0.045) lateral frontal orbital gyri predicted MDRS I/P, whereas education (β=0.385, p<0.001) and left lateral frontal orbital gyrus (β=0.222, p=0.037) predicted MMSE. Volumes of WML and cognitively relevant brain regions were significantly associated. Seven patients with PIB imaging showed no uptake pattern typical of Alzheimer's disease, suggesting a predominantly vascular aetiology for the cognitive impairment and brain changes in these patients.

CONCLUSIONS

Cognitive impairment in patients with confluent WML is mediated by global and frontal cortical atrophy.

Psychosocial condition of family caregivers of patients with chronic obstructive pulmonary disease in Hong Kong

OBJECTIVES. Chronic obstructive pulmonary disease is associated with physical and psychological burdens. Although there is research about health-related quality of life (HRQOL) of such patients, less is known about the psychosocial condition of their family caregivers. The objectives of this study were to examine the HRQOL and the burden of chronic obstructive pulmonary disease patient caregivers, and to identify associated relevant factors. METHODS. A total of 81 eligible caregivers completed a caregiver survey on HRQOL (Short Form-36 Questionnaire), caregiving burden (Cumulative Illness Rating Scale, CIRS) and other biopsychosocial factors. Descriptive statistics, correlations, and multiple linear regression models were used to analyse data. RESULTS. The caregiver's Mental Component Summary measure of the Short Form-36 was associated with each caregiver's total CIRS scores, the anxiety subscale of the Hospital Anxiety and Depression Scale, and the Lubben Social Network Scale. The caregiver's Physical Component Summary measure was associated with the patient's disability allowance, the caregiver's total CIRS score, and the Barthel Index score. Caregivers' Caregiving Burden Scale scores were associated with their Geriatric Depression Scale total score and the need to take care of other family members. CONCLUSIONS. This study demonstrates that depressive and anxiety symptoms are associated with caregivers' burden and HRQOL. Further studies on evaluating interventions on caregivers' HRQOL and burden should take mood symptoms into consideration.

White matter hyperintensities in post-stroke depression: a case control study

OBJECTIVE

Despite extensive research on post-stroke depression (PSD), the role of white matter hyperintensities (WMHs) in its pathogenesis remains uncertain. The aim of this study was to evaluate the relationship between WMHs and PSD in Chinese patients with first or recurrent stroke.

METHODS

A cohort of 994 patients with acute ischaemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong was recruited. A psychiatrist administered the Structural Clinical Interview for DSM-IV to all patients and made a diagnosis of PSD 3 months after the index stroke. 78 (7.8%) patients had PSD; 78 stroke patients matched according to age and sex but without PSD served as a control group. The severity and location of WMHs were evaluated with MRI.

RESULTS

In comparison with the non-PSD group, patients in the PSD group were more likely to have severe deep WMHs (12.8% vs 1.3%; p=0.009). Severe deep WMHs remained an independent predictor of PSD in the multivariate analysis with an OR of 13.8 (p=0.016).

CONCLUSION

The results suggest that WMHs may play a role in the development of PSD. The importance of WMHs in the treatment and outcome of PSD warrants further investigation.

Microbleeds and post-stroke emotional lability

OBJECTIVE

The clinical significance of microbleeds (MBs) in the development of psychiatric conditions following a stroke is unknown. Lesions located in various cortical and subcortical areas are thought to be involved in the pathophysiology of post-stroke emotional lability (PSEL). This study examined the association between PSEL and MBs.

METHODS

A total of 519 Chinese patients with acute ischaemic stroke consecutively admitted to the acute stroke unit of a university affiliated regional hospital in Hong Kong were screened for PSEL 3 months after their index stroke. The number and location of MBs were evaluated with MRI.

RESULTS

According to Kim's criteria, 74 (14.3%) patients had PSEL. In comparison with the non-PSEL group, patients in the PSEL group were more likely to have MBs in the thalamus as a whole (16.2% vs 6.5%; p = 0.004), its anterior (6.9% vs 2.0%, p = 0.02) and paramedian territories (8.1% vs 3.1%; p = 0.04), and a higher number of MBs in the entire brain (1.7+3.4 vs 1.3+5.0; p = 0.031). MBs in the thalamus remained an independent predictor of PSEL in the multivariate analysis, with an odds ratio of 4.7 (p = 0.002).

CONCLUSION

Our results suggest that MBs in the thalamus may play a role in the development of PSEL. The importance of MBs in PSEL and other psychiatric conditions in stroke survivors warrants further investigation.

Establishment and characterization of a new xenograft-derived human esophageal squamous cell carcinoma cell line HKESC-4 of Chinese origin

A new human esophageal cancer cell line, HKESC-4, was established from a nude-mouse xenograft of a moderately differentiated esophageal squamous cell carcinoma (ESCC) developed from a 65-year-old Hong Kong Chinese man. The cellular characteristics (morphological, electron microscopic, and immunohistochemical studies), tumorigenicity in athymic nude mice, cytogenetic features, and DNA ploidy of the cell line were investigated. The cell line was maintained in vitro for 17 months and passaged 80 times. HKESC-4 grew as a monolayer, with a doubling time of 63 hours. The epithelial nature of HKESC-4 included the presence of cytokeratin intermediate filaments, as shown by antibodies (AE1/AF3, CAM5.2, and MAK 6), and the presence of the tonofilaments, as seen under electron microscopy. HKESC-4 was tumorigenic in nude mice and had DNA aneuploidy. The cytogenetic abnormalities of HKESC-4 included -1, -2, -3, -4, -5, -6, -7, -8, -9, -10, -11, -12, -15, -16, -17, -18, -19, +20, -21, -22, +del(11)(p11), +i(11)(q10), and +21 marker chromosomes. Comparative genomic hybridization analysis demonstrated chromosomal gains at 1p36.13, 3q23 approximately q28, 5p15.33 approximately p15.1, 6p25.1 approximately p22.3, 7p21.3 approximately p11.2, 7q11.21 approximately q21.13, 8q23.3 approximately q23.3, 11p11.2, 11q12.1 approximately q13.2, 14q21.3 approximately q32.2, 17p13.3, 18p11.32 approximately p11.31, and 20p13 approximately p12.2 and chromosomal losses at 1q12, 2p25.1 approximately p24.3, 13p13 approximately p11.2, 21p, 22p13 approximately p11.2, and Y. The newly established cell line HKESC-4 promises to be a useful tool in future studies of molecular pathogenesis and therapeutics in ESCC.

Prevalence and correlates of depression in Chinese elderly patients with pneumoconiosis

Recent literature suggests that patients with pneumoconiosis may be at higher risk of developing psychiatric problems, particularly depressive illness. There are no published data on depressive disorders in elderly patients with pneumoconiosis. The aim of this study was to evaluate the prevalence and correlates of depressive disorders in a community sample of elderly Chinese patients with pneumoconiosis in Hong Kong. Two hundred and one patients with pneumoconiosis were randomly selected from the case register of the Pneumoconiosis Compensation Fund Board of Hong Kong. A psychiatrist conducted a structured clinical interview to diagnose depressive disorders according to the Diagnostic Statistical Manual for Mental Disorders, Version IV criteria. Nineteen (9.5%) patients had depressive illness. Univariate logistic regression revealed that the number of comorbid conditions, and the scores on the Lubben Social Network Scale (LSNS) and Instrumental Activities of Daily Living (IADL) were significant predictors of depressive disorders. Multivariate logistic regression analysis found that IADL and LSNS scores were the only independent predictors of depressive disorders. In conclusion, depressive disorders were common and associated with poorer functional ability and social support in patients with pneumoconiosis.

Screening post-stroke depression in Chinese older adults using the hospital anxiety and depression scale

Little is known about the performance of the Hospital Anxiety and Depression Scale (HADS) in screening post-stroke depression (PSD) in Chinese older adult patients. One hundred Chinese geriatric patients with first-ever stroke, consecutively admitted to a rehabilitation facility, were assessed by occupational therapists using the depression subscale of the HADS. Psychiatric diagnoses, which served as the benchmark for judging the usefulness of HADS in screening PSD, were made using the Structured Clinical Interview for DSM-III-R (SCID-DSM-III-R) supplemented by all available clinical information. The optimal cut-off point of HADS was 6/7. The sensitivity, specificity, positive and negative predictive value of the HADS, and the area under the receiver operating characteristic curve, were 88%, 53%, 0.28, 0.96 and 0.75, respectively. The HADS does not appear to be a useful tool in screening for PSD in Chinese older adults.

Cognitive impairment and functional outcome after stroke associated with small vessel disease

OBJECTIVES

Although stroke associated with small vessel disease (SSVD) can induce both motor and cognitive impairment, the latter has received less attention. We aimed to evaluate the frequency of the varying severity levels of cognitive impairment, the determinants of severe cognitive impairment, and the association of cognitive impairment with functional outcome after SSVD.

METHODS

Consecutive patients admitted to hospital because of SSVD were assessed at 3 months after stroke. We performed a semi-structured clinical interview to screen for cognitive symptoms. Severity of cognitive symptoms was graded according to the Clinical Dementia Rating Scale (CDR). Performance on psychometric tests (Mini-Mental State Examination, Alzheimer's Disease Assessment Scale (cognition subscale), Mattis Dementia Rating Scale (initiation/perseverence subscale; MDRS I/P)) of patients of different CDR gradings was compared with that of 42 healthy controls. Basic demographic data, vascular risk factors, stroke severity (National Institute of Health Stroke Scale; NIHSS), pre-stroke cognitive decline (Informant Questionnaire on Cognitive Decline in the Elderly; IQCODE), functional outcome (Barthel index; BI), Instrumental Activities Of Daily Living; IADL), and neuroimaging features (site of recent small infarcts, number of silent small infarcts, white matter changes) were also compared among the groups. Regression analyses were performed to find predictors of severe cognitive impairment and poor functional outcome.

RESULTS

Among the 75 included patients, 39 (52%) complained of cognitive symptoms. The number of patients in each CDR grading was as follows: 39 (52%) had a CDR of 0, 26 (34.7%) had a CDR of 0.5, 10 (13.3%) had a CDR of > or =1. Pre-stroke IQCODE and previous stroke predicted CDR> or =1. The NIHSS was associated with more impaired BI. The NIHSS and MDRS I/P contributed most to impaired IADL.

CONCLUSIONS

Half of the patients with SSVD complained of varying severity of cognitive problems 3 months after stroke. Pre-stroke cognitive decline and previous stroke predict severe cognitive impairment post stroke. Stroke severity and executive dysfunction contribute most to a poor functional outcome.

Three patients with orbital xanthogranuloma and non-progressive haematological abnormalities

Orbital xanthogranuloma is a rare dermatological condition characterized by its bilateral and rather symmetrical subcutaneous granulomatous infiltration around the eyes. It shares morphological similarities with other xanthogranulomatous diseases such as juvenile or adult type xanthogranuloma, necrobiotic xanthogranuloma and cutaneous infiltration in Erdheim-Chester disease, and should be differentiated from them. Three elderly Chinese patients with this condition were found to have underlying haematological abnormalities: normochromic normocytic anaemia, thrombocytopenia or eosinophilia. Their skin lesions remained localized and associated haematological abnormalities stable for up to 7 years. Haematological abnormalities were also reported in previous cases and this finding is unlikely to be coincidental; however, its clinical significance remains unknown.

Prescribing for inpatients with schizophrenia: an international multi-center comparative study

BACKGROUND

This study compares prescription practices for acute inpatients with schizophrenia among six academic departments located in China, Japan, Hungary, and the U.S.

METHODS

Prescription data for a sample of 429 inpatients from six academic departments were collected on a randomly chosen census day. All patients met criteria for schizophrenia according to DSM-IV and had a length of illness of at least two years.

RESULTS

While patients at the different centers varied in their demographic and clinical characteristics, i. e., age, sex, and length of illness, a great variation in prescription patterns for antipsychotic and other psychotropic drugs among centers was observed even within the same country for all the variables studied (i. e., number and dose antipsychotics, atypical and depot antipsychotics, other psychotropic drugs, multiple antipsychotics, and daily dose) except antidepressant use. In most cases these differences persisted even after adjusting for demographic and clinical characteristics (age, sex, and length of illness) of the subjects. Antipsychotics were usually prescribed in divided daily doses in combination with one or more other psychotropic drugs, including anticholinergics, anticonvulsants, benzodiazepines, and non-benzodiazepine hypnotics. Anticholinergic use was more common with typical antipsychotics. Rates of atypical antipsychotic drug use were lowest in the Japanese center. The Japanese center had by far the highest mean daily dose of antipsychotics.

CONCLUSIONS

The results indicate that prescription patterns in different centers do not follow any specific guidelines for the treatment of schizophrenia. The results also confirm previous findings that prescribing practices for schizophrenia vary greatly among centers and countries. A common prescribing pattern found was the use of atypical antipsychotic drugs in combination with psychotropic drugs, such as anticholinergics, hypnotics, anticonvulsants, and benzodiazepines, administered in multiple daily doses.

Dopamine D3 receptor gene and tardive dyskinesia in Chinese schizophrenic patients

Epidemiological studies have shown a lower prevalence of tardive dyskinesia (TD) among Chinese psychiatric patients compared to Caucasian and Black patient populations. It has been hypothesized that pharmacogenetic factors may underlie this cross-cultural difference. Due to the important implications of the dopamine D3 receptor gene (DRD3) in motor control, we investigated the frequency of polymorphic serine (ser) to glycine (gly) substitution of the gene DRD3 in Chinese schizophrenic patients. The sample size consisted of 65 patients with TD and 66 without TD. Patients were assessed for the severity of TD, the presence of akathisia and parkinsonian symptoms and were subsequently genotyped. We found no evidence that the dopamine D3 receptor gene is likely to confer susceptibility to the development of tardive dyskinesia in Chinese patients with schizophrenia.

Cytochrome P450 2D6 genotyping and association with tardive dyskinesia in Chinese schizophrenic patients

BACKGROUND

The discovery of Cytochrome P450 2D6 (CYP 2D6) polymorphism is implicated in individual differences in drug metabolism rate. Mutation with defective alleles is associated with reduced metabolism of many anti-psychotic drugs metabolized by CYP 2D6. This may contribute to the development of tardive dyskinesia (TD) in patients with prolonged exposure to anti-psychotic drugs.

METHODS

In this controlled study, the genotype of CYP 2D6*10 alleles, movement disorders and clinical characteristics in 38 Chinese schizophrenic patients with TD were compared with 38 age- and sex-matched schizophrenia patients without TD.

RESULTS

There was no significant correlation between CYP 2D6*10 genotypes and TD in men. However, a significant increase in the frequency of CYP 2D6*10 allele was found in female patients with TD.

CONCLUSIONS

The sex differences in CYP 2D6 genotyping and vulnerability to develop TD suggest that a biological predisposition that affects pharmacokinetics may be more significant in women, whereas other factors may be more important in men.

Asystole during electroconvulsive therapy: a case report

OBJECTIVE

The objective of the report is to describe a case of asystole lasting for 18 s, which developed after a subconvulsive stimulus during electroconvulsive therapy (ECT) in a patient without pre-existing cardiovascular abnormality. A brief review of the relevant literature is also provided.

CLINICAL PICTURE

The patient was a 65-year-old Chinese man with a 2-year history of depression and good past medical health. Earlier he had responded well to a course of ECT without adverse effects. This time he presented with low mood, anhedonia, poor appetite and constipation. He did not respond to adequate trials with several antidepressant medications. When a subconvulsive stimulus was administered to determine the seizure threshold, no seizure activity was detected. However, immediately after the stimulus the patient developed an 18-s asystole, followed by bradycardia of 40 beats per minute for 10 s. The bradycardia resolved spontaneously before therapeutic intervention was effected.

TREATMENT

Intravenous atropine was employed as premedication and suprathreshold stimulus was used in further ECT sessions.

OUTCOME

Asystole did not recur in the subsequent six ECT sessions.

CONCLUSION

When proper precautions are taken, asystole does not necessitate the suspension of further ECT sessions but intravenous atropine should be considered as premedication in such cases. Inducing anaesthesia with methohexital, avoiding excessive amounts of succinylcholine and employing suprathreshold stimulus and unilateral electrode placement may further lessen the likelihood of asystole in susceptible cases.

Behavioral profile of Alzheimer's disease in Chinese elderly--a validation study of the Chinese version of the Alzheimer's disease behavioral pathology rating scale

OBJECTIVES

This study aims to examine the psychometric properties of the Chinese version of the Alzheimer's disease behavioral pathology rating scale (CBehave-AD) and the behavioral profile of Chinese patients with AD.

METHODS

Seventy-one subjects with NINCDS-ADRDA diagnosis of probable and possible AD were assessed for validation of the CBehave-AD. A behavioral symptom frequency checklist, the Chinese version of the Blessed Roth dementia scale (CDS) and the Cantonese version of the Mini-Mental State Examination (CMMSE) were used for comparison. An extended sample of 120 AD patients was then evaluated with the CBehave-AD.

RESULTS

High correlations between the CBehave-AD and checklist scores were found (paranoid and delusional ideation, hallucinations, activity disturbances, aggressiveness and diurnal rhythm disturbances). The scale also demonstrated satisfactory inter-rater and test-retest reliabilities. The mean (SD) CMMSE score of the 120 patients was 9.4 (7.1). Among them, 32% have delusions, 15% had hallucinations, 54% had activity disturbances, 61% had aggressive behavior, 44% had sleep disturbance, 24% had affective disturbances, 19% had anxiety and phobias. Delusional ideation was significantly associated with hallucinations, aggressiveness, and affective disturbances. Diurnal rhythm disturbances were associated with activity disturbances and aggressiveness. CBehave-AD total scores were not significantly correlated with severity of AD, but individual symptom categories showed different pattern of correlation. Delusions, hallucinations, anxiety and phobias were significantly correlated with dementia staging.

CONCLUSION

The findings suggest that the CBehave-AD is a valid assessment tool for behavioral disturbances in patients with AD. Variable associations between different symptom categories and dementia staging suggest a need for further exploration of the complex interactions between behavioral and cognitive disturbances in dementia.

Electroconvulsive therapy in rehabilitation: the Hong Kong experience

Persistent psychotic symptoms can intrude on an individual's cognitive and psychosocial functioning and interfere with that person's active and constructive participation in social and vocational rehabilitation. Amelioration or elimination of intrusive positive and negative symptoms of psychosis is the major task for clinicians during the acute phase of schizophrenia. Successful treatment permits the patient to transition into stabilization and recovery phases, when psychosocial rehabilitation can take primacy (1). The introduction of clozapine has enlarged the proportion of individuals with schizophrenia whose psychotic symptoms can be controlled (2), but symptoms remain refractory in a large number of patients. One largely unexplored alternative for treating individuals who are chronically disabled is electroconvulsive therapy (ECT). Already known for its efficacy in treating affective disorders, its effectiveness in treating schizophrenia--although more limited--has been documented over more than five decades (3,4). ECT has been found to be particularly effective in treating first-episode cases in which affective and catatonic symptoms are manifested and in 20 to 50 percent of treatment-resistant cases, including those in which the patient was nonresponsive to clozapine (5,6,7,8). Without continuation and maintenance ECT, however, results are usually short-lived (4,7,9). Tang and Ungvari have used ECT in an attempt to increase the responsiveness to psychosocial rehabilitation of patients who have treatment-refractory schizophrenia. They describe their experiences with ECT at a facility in Hong Kong, where long-term hospitalization is still the norm for a sizable proportion of patients with chronic schizophrenia. ECT is more compatible with the biological view of schizophrenia that is prevalent in Asian countries; hence it has greater cultural congruence and acceptability among consumers and families in China than in the United States.

Telepsychiatry in psychogeriatric service: a pilot study

A pilot study on telepsychiatry was conducted in which a videoconferencing link was established between a regional hospital and a care and attention home. Using this system, a psychogeriatric outreach team provided 149 psychiatric assessments to 45 residents of the care and attention home over 11 months. Videoconferencing was found to be highly feasible. It was acceptable to staff and patients and more cost-effective than on-site visits.

Reactive psychosis: a classical category nearing extinction?

By presenting two illustrative case histories, the authors stress the importance of the classical category of reactive psychosis which has disappeared from recent international classifications as a distinct nosological entity. Reactive psychosis is essential in the differential diagnosis of acute psychoses as the diagnosis of reactive psychosis has far-reaching therapeutic implications. Clinical and conceptual issues concerning reactive psychosis are briefly reviewed with respect to major classical and modern papers.

Lorazepam for chronic catatonia: a randomized, double-blind, placebo-controlled cross-over study

Acute catatonic syndromes occurring in the context of various medical and neuropsychiatric conditions, including schizophrenia, have been shown to respond well to benzodiazepines (BZD). However, there have been no studies specifically designed to address the BZD treatment response of persistent catatonic states. Eighteen patients with clinically stable chronic schizophrenia, who also displayed enduring catatonic features, underwent a 12-week long, random assignment, double-blind, placebo-controlled cross-over trial with lorazepam (6 mg/day). A comprehensive assessment, including the subjects' clinical and motor (catatonic as well as drug-induced movement disorders) condition, was performed at baseline and four weekly intervals thereafter. Pre-existing medication was kept constant throughout the study. Lorazepam had no effect on the subjects' catatonic signs and symptoms, suggesting that acute and chronic catatonic syndromes associated with schizophrenic illness might have a different neurobiological basis.