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Huntington's disease (HD) is an inherited neurodegenerative disease involving motor, cognitive, psychiatric, and behavioral impairments that eventually affect work-role functioning. There is limited research regarding predictors of workplace disability in HD. The authors examined predictors of work impairment and disability in a cross-sectional cohort of employed persons with symptomatic HD participating in the worldwide Enroll-HD study.The study sample (N=316) comprised individuals with manifest HD and a CAG repeat length range between 39 and 60 and were currently engaged in paid full- or part-time employment. Univariate and multivariate logistic regression analyses identified predictors and the effect of all predictors in a fully adjusted model.Of the sample, 20.3% reported missing work due to HD, 60.1% reported experiencing impairment while working due to HD, 79.1% reported having work-related activity impairment due to HD, and 60.8% reported impairment in overall work productivity due to HD. Individuals had 25% higher odds of missing work time if they had a higher level of functional impairment (odds ratio=0.76, 95% CI=0.64, 0.91) and had three times greater odds of missing work if they were current alcohol drinkers, compared with nondrinkers (odds ratio=2.86, 95% CI=1.62, 5.03). Individuals with lower self-perceived mental health were also 5% more likely to experience impairment at work due to HD. Motor impairment was not a strong predictor of workplace disability.These findings provide important new knowledge that can inform the development of strategies or targeted intervention trials to support persons with symptomatic HD to maintain their work roles.

β-Ketosulfonamides derived from Boc or Cbz-protected amino acids bearing hydrophobic side chains were prepared in good to excellent yield by treating N-allyl, N-alkyl methanesulfonamides with n-BuLi, followed by reaction of the resulting carbanion with methyl esters of N-protected l-amino acids. The analogous reaction using the dianion derived from an N-alkyl methanesulfonamide proceeded in much lower yield. Electrophilic fluorination of the β-ketosulfonamides using Selectfluor in the presence of CsF in DMF at room temperature for 15–60 min provided β-keto-α,α-difluorosulfonamides in good to excellent yields. The allyl protecting group could be removed in good yield using cat. Pd(PPh)3)4 and dimethyl barbituric acid. When the fluorination reaction was performed with Cs2CO3 as base, β-ketosulfonamides derived from Val, Leu or Ile gave the expected β-keto-α,α-difluorosulfonamides, while β-ketosulfonamides derived from Ala, Phe, or hPhe gave the hydrates of the imino β-keto-α,α-difluorosulfonamides.

Huntington disease (HD) is a neurodegenerative condition with prominent motor (including oculomotor), cognitive, and psychiatric effects. While neuropsychological deficits are present in HD, motor impairments may impact performance on neuropsychological measures, especially those requiring a speeded response, as has been demonstrated in multiple sclerosis and schizophrenia. The current study is the first to explore associations between oculomotor functions and neuropsychological performance in HD. Participants with impaired oculomotor functioning performed worse than those with normal oculomotor functioning on cognitive tasks requiring oculomotor involvement, particularly on psychomotor speed tasks, controlling for covariates. Consideration of oculomotor dysfunction on neuropsychological performance is critical, particularly for populations with motor deficits.

Huntington disease (HD) is a neurodegenerative disorder that involves preferential atrophy in the striatal complex and related subcortical nuclei. In this article, which is based on a dataset extracted from the PREDICT-HD study, we use statistical shape analysis with deformation markers obtained through "Large Deformation Diffeomorphic Metric Mapping" of cortical surfaces to highlight specific atrophy patterns in the caudate, putamen, and globus pallidus, at different prodromal stages of the disease. On the basis of the relation to cortico-basal ganglia circuitry, we propose that statistical shape analysis, along with other structural and functional imaging studies, may help expand our understanding of the brain circuitry affected and other aspects of the neurobiology of HD, and also guide the most effective strategies for intervention.

This paper summarizes the history of the development of Chinese mental health system; the current situation in the mental health field that China has to face in its effort to reform the system, including mental health burden, workforce and resources, as well as structural issues; the process of national mental health service reform, including how it was included into the national public health program, how it began as a training program and then became a treatment and intervention program, its unique training and capacity building model, and its outcomes and impacts; the barriers and challenges of the reform process; future suggestions for policy; and Chinese experiences as response to the international advocacy for the development of mental health.

CONTEXTO: A Seção de Psiquiatria Geriátrica da Associação Mundial de Psiquiatria (AMP), desde 1997, vem desenvolvendo Declarações de Consenso relevantespara a prática da Psiquiatria Geriátrica. Desde 2006, a Seção vem trabalhando para desenvolver uma Declaração de Consenso sobre Ética e Capacidade em pessoas idosas com transtornos mentais. MÉTODO: Uma Conferência de Consenso foi realizada em Praga em setembro de 2008. Organizada pela Seção de Psiquiatria da Pessoa Idosa da AMP, ela contou com a participação do International Council of Nurses, Alzheimer Europe e Alzheimer Disease International. Os participantes foram reconhecidos pela sua perícia nesse domínio e vieram de 11 países. Incluíam psiquiatras, uma neurologista, um enfermeiro e representantes de cuidadores familiares. RESULTADOS: Após dois dias de reuniões e debate, redigiu-se um rascunho da declaração que foi submetida para análise nas diversas organizações/associações que participaram da reunião. Após as sugestões finais recolhidas, um texto definitivo foi preparado em inglês e publicado. A presente versão em português é da responsabilidade de dois participantes lusófonos da reunião, que são também coautores da declaração de consenso final. CONCLUSÕES: Essa Declaração de Consenso oferece aos clínicos em saúde mental que cuidam de pessoas idosas com transtornos mentais, cuidadores, outros profissionais da saúde e o público em geral as definições e o debate sobre os princípios éticos que podem frequentemente ser complexos e desafiadores, apoiados em orientações práticas para satisfazer tais necessidades e padrões éticos e encorajar a boa prática clínica.BACKGROUND: The World Psychiatric Association (WPA) Section of Old Age Psychiatry, since 1997, has developed Consensus Statements relevant to the practice of Old Age Psychiatry. Since 2006 the Section has worked to develop a Consensus Statement on Ethics and Capacity in older people with mental disorders. METHOD: A Consensus Conference was realized in Prague, September 2008. The meeting was organized by the WPA Section of Old Age Psychiatry, with the participation of International Council of Nurses, Alzheimer Europe and Alzheimer Disease International. Participants who are recognised for their expertise in this area came from 11 countries and include psychiatrists, a neurologist, a nurse and family caregiving representatives. RESULTS: After two days of debate a draft was prepared and submitted to the organizations/associations represented at the meeting. When their respective comments were collected, a final text was prepared and published originally in English. This Portuguese version was prepared by two members of the meeting who came from Portuguese spoken countries. DISCUSSION: This Consensus Statement offers to mental health clinicians caring for older people with mental disorders, caregivers, other health professionals and the general public the setting out of and discourse in ethical principles which can often be complex and challenging, supported by practical guidance in meeting such ethical needs and standards, and to encouraged good clinical practice.

CONTEXTO: A Secao de Psiquiatria Geriatrica da Associacao Mundial de Psiquiatria (AMP), desde 1997, vem desenvolvendo Declaracoes de Consenso relevantespara a pratica da Psiquiatria Geriatrica. Desde 2006, a Secao vem trabalhando para desenvolver uma Declaracao de Consenso sobre Etica e Capacidade em pessoas idosas com transtornos mentais. METODO: Uma Conferencia de Consenso foi realizada em Praga em setembro de 2008. Organizada pela Secao de Psiquiatria da Pessoa Idosa da AMP, ela contou com a participacao do International Council of Nurses, Alzheimer Europe e Alzheimer Disease International. Os participantes foram reconhecidos pela sua pericia nesse dominio e vieram de 11 paises. Incluiam psiquiatras, uma neurologista, um enfermeiro e representantes de cuidadores familiares. RESULTADOS: Apos dois dias de reunioes e debate, redigiu-se um rascunho da declaracao que foi submetida para analise nas diversas organizacoes/associacoes que participaram da reuniao. Apos as sugestoes finais recolhidas, um texto definitivo foi preparado em ingles e publicado. A presente versao em portugues e da responsabilidade de dois participantes lusofonos da reuniao, que sao tambem coautores da declaracao de consenso final. CONCLUSOES: Essa Declaracao de Consenso oferece aos clinicos em saude mental que cuidam de pessoas idosas com transtornos mentais, cuidadores, outros profissionais da saude e o publico em geral as definicoes e o debate sobre os principios eticos que podem frequentemente ser complexos e desafiadores, apoiados em orientacoes praticas para satisfazer tais necessidades e padroes eticos e encorajar a boa pratica clinica.

Academic Unit for Psychiatry of Old Age, St Georges Hospital, The University of Melbourne, Melbourne, AustraliaCorrespondenceAnita Mei Yoke Goh DPsych, Academic Unitfor Psychiatry of Old Age, The University ofMelbourne, St Georges Hospital, 283 CothamRoad, Kew, Vic. 3101, Australia.Tel: 161 3 9816 0513Fax: 161 3 9816 0403Email: goha@unimelb.edu.auDOI:10.1111/j.1758-5872.2009.00017.x

The reporting of child sexual abuse (CSA) and physician-patient sexual relationships (PPSR) are currently the focus of professional, legal and media attention in several countries. This paper briefly reviews mental health policies on these issues and reports on a WPA survey of them. While the WPA Madrid Declaration permits breaching confidentiality for mandatory reporting of CSA and clearly prohibits PPSR, it is not known how or to what extent these policies are implemented in WPA Member Societies’ countries. It is also not known whether policies or laws exist on these topics nationally or to what extent psychiatrists and the public are aware of them. Representatives of WPA Member Societies were e-mailed a survey about issues pertaining to CSA and PPSR. Fifty-one percent of 109 countries replied. All reporting countries had laws or policies regarding the reporting of CSA, but this was often voluntary (63%) and without protection for reporting psychiatrists either by law (29%) or by Member Societies (27%). A substantial number of psychiatric leaders did not know the law (27%) or their Society’s policy (11%) on these matters. With respect to PPSR, some reporting countries lacked laws or policies about PPSR with current (17%) or past (56%) patients. Fewer than half of responding representatives believed that their Society’s members or the public were well informed about the laws and policies pertaining to CSA or PPSR. There is clearly a wide range of laws, policies and practices about CSA and PPSR in WPA Member Societies’ countries. There is a need in some countries for laws or supplemental policies to facilitate the protection of vulnerable child and adult patients through clear, mandatory reporting policies for CSA and PPSR. Mechanisms to protect and support reporting psychiatrists should also be developed where they do not already exist. There is also a need in some countries to develop strategies to improve the education of psychiatrists, trainees, and the public on these issues.

The uptake of predictive testing for Huntington disease informs our understanding of decision making by those at risk and assists with planning for service provision. Uptake figures have been reported from several centers based on the total number of people who have undertaken predictive testing as a percentage of those estimated to be at 50% risk in the region. This method produced a figure of 35% from our own service, much higher than observation of the local pedigrees indicated, and higher than other published reports. We have identified some errors in the commonly used formula. The major errors are the use of the cumulative total of those who have had testing with a static denominator of those at 50% risk, and the failure to exclude from the at-risk group those who are too young and therefore ineligible to test.We report data from the Huntington Disease Register of Victoria and estimate the prevalence to be 8 per 100,000 in 1999. Additional data on individuals at risk were collated. We found that for every diagnosed person there were 4.2 individuals at 50% risk, a lower ratio than one to five hypothesized in the literature. We examined these ratios in the context of uptake.Significantly, we provide a solution to the calculation of uptake with a formula that factors in a dynamic denominator and corrects for the number of years testing has been offered. Using this formula, we calculated an uptake of 13.0-15.4% for the state of Victoria, Australia. This formula can be used to compare uptake across different centers.

The primary impairment in early Alzheimer's disease (AD) is encoding/consolidation, resulting from medial temporal lobe (MTL) pathology. AD patients perform poorly on cued-recall paired associate learning (PAL) tasks, which assess the ability of the MTLs to encode relational memory. Since encoding and retrieval processes are confounded within performance indexes on cued-recall PAL, its specificity for AD is limited. Recognition paradigms tend to show good specificity for AD, and are well tolerated, but are typically less sensitive than recall tasks. Associate-recognition is a novel PAL task requiring a combination of recall and recognition processes. We administered a verbal associate-recognition test and cued-recall analogue to 22 early AD patients and 55 elderly controls to compare their ability to discriminate these groups. Both paradigms used eight arbitrarily related word pairs (e.g., pool-teeth) with varying degrees of imageability. Associate-recognition was equally effective as the cued-recall analogue in discriminating the groups, and logistic regression demonstrated classification rates by both tasks were equivalent. These preliminary findings provide support for the clinical value of this recognition tool. Conceptually it has potential for greater specificity in informing neuropsychological diagnosis of AD in clinical samples but this requires further empirical support. (JINS, 2008,14, 591–600.)

© 2015 Wiley Periodicals, Inc. Huntington disease (HD) is most widely known for its selective degeneration of striatal neurons but there is also growing evidence for white matter (WM) deterioration. The primary objective of this research was to conduct a large-scale analysis using multisite diffusion-weighted imaging (DWI) tractography data to quantify diffusivity properties along major prefrontal cortex WM tracts in prodromal HD. Fifteen international sites participating in the PREDICT-HD study collected imaging and neuropsychological data on gene-positive HD participants without a clinical diagnosis (i.e., prodromal) and gene-negative control participants. The anatomical prefrontal WM tracts of the corpus callosum (PFCC), anterior thalamic radiations (ATRs), inferior fronto-occipital fasciculi (IFO), and uncinate fasciculi (UNC) were identified using streamline tractography of DWI. Within each of these tracts, tensor scalars for fractional anisotropy, mean diffusivity, radial diffusivity, and axial diffusivity coefficients were calculated. We divided prodromal HD subjects into three CAG-age product (CAP) groups having Low, Medium, or High probabilities of onset indexed by genetic exposure. We observed significant differences in WM properties for each of the four anatomical tracts for the High CAP group in comparison to controls. Additionally, the Medium CAP group presented differences in the ATR and IFO in comparison to controls. Furthermore, WM alterations in the PFCC, ATR, and IFO showed robust associations with neuropsychological measures of executive functioning. These results suggest long-range tracts essential for cross-region information transfer show early vulnerability in HD and may explain cognitive problems often present in the prodromal stage.

The elderly psychiatrically ill constitute a high proportion of the patients who receive electroconvulsive therapy (ECT). There is evidence to say that the efficacy of ECT may be enhanced in the elderly. Clinical and biological markers are increasingly being recognised as predictors of outcome to ECT. The doses of anticholinergic, anaesthetic and relaxant agents may need to be modified in accordance with physiological changes associated with aging. ECT stimulus and ECT technique should be selected against the background of increased seizure threshold and possibility of greater ECT-induced cognitive dysfunction in the elderly, particularly those with pre-existing cognitive or neurologic impairment. New brain-imaging techniques and biochemical measures of brain damage have proved that ECT does not cause brain damage. The physical risk with ECT is considered to be low. There is some evidence to say that cardiovascular complications reported with ECT are related to the nature of pre-existing cardiac disease. Although the short-term response to ECT in the elderly is quite good, post-ECT relapse rates are quite high. Continuation-maintenance ECT has a definite role in minimising relapses and recurrences in the elderly, taking care not to enhance physical and cognitive risks. With increasing administration of outpatient ECT, it is important to refine methods for monitoring patients for adverse effects of treatment. The roles of repetitive trans-cranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS) in geriatric psychiatry are yet to be established.

Mental rotation (MR) performance may be used as an index of mental slowing or bradyphrenia, and may reflect, in particular, speed of motor preparation. MR was employed with a sample of both melancholic (na 8) and non-melancholic (na 9) unipolar depressed patients and healthy controls (na 10) to determine if motor slowing associated with depression might be reflected in slowed motor preparation (as reflected in slope of the MR function) independent of actual motor slowing (overall response time). Both melancholic and non-melancholic patients showed a generalised slowing relative to controls, perhaps reflecting bradykinesia and akinesia. This effect was significantly greater in the melancholic group than in the non-melancholic group. Relative to both the controls and the non-melancholic groups, the melancholic patients showed a progressive slowing with increasing angle of orientation indicating a specific slowing of MR. This deficit suggests a role of slowed motor planning in the psychomotor retardation of patients with melancholic depression.

The International Psychogeriatric Association (IPA) being the leading international organization in the promotion of mental health and effective treatment of mental disorders in the elderly, has a long standing enviable tradition and track record in providing leadership in this field.

Adoptive immunity transfer has been reported to be effective in clearing chronic hepatitis B virus (HBV) infection. Two hundred twenty-six patients who received allogeneic bone marrow transplantation (BMT) between May 1990 and September 1995 were screened for hepatitis B markers. Twenty-one patients were hepatitis B surface antigen (HBsAg) positive before BMT. The median follow-up period was 20 months (range, 2-59 months). Two of these patients had sustained clearance of HBV infection after transplantation. Both patients were hepatitis B e antigen (HBeAg)-negative, hepatitis B e antibody (anti-HBe)-positive, and serum HBV DNA-negative (by dot-blot hybridization) before BMT. Both had a flare in the serum alanine transaminase (ALT) level around the time of HBsAg clearance. Sustained clearance of HBsAg was observed in 2 of the 5 patients who received hepatitis B surface antibody (anti-HBs)-positive marrow but in none of the 16 patients who received anti-HBs-negative marrow (P < .05). One additional patient who received anti-HBs-positive marrow had transient HBsAg seroconversion. Among the 18 patients who remained persistently HBsAg-positive after BMT, 3 had HBeAg seroconversion and 3 had reversion to HBeAg positivity. In this study, we found a significant association between clearance of HBV infection and anti-HBs-positive bone marrow donors. Adoptive immunity transfer is effective in clearing HBV from patients with chronic HBV infection.

Hepatitis B reactivation following chemotherapy withdrawal may result in hepatitis, hepatic failure and death. We studied the clinical outcome and the causes of hepatic events of hepatitis B surface antigen positive recipients undergoing bone marrow transplantation. Twenty-four hepatitis B surface antigen patients were matched with 24 hepatitis B surface antigen negative patients for age, sex, CMV positive serology, underlying hematological disease and type of bone marrow transplantation. Post-BMT, there were 18 patients in the hepatitis B surface antigen positive group and four patients in the hepatitis B surface antigen negative group who suffered from hepatitis (P < 0.05). Thirteen of the 18 hepatitis were related to HBV reactivation in the hepatitis B surface antigen positive group and none of the four hepatitis in the hepatitis B surface antigen negative group (P = 0.01). The hepatitis B surface antigen positive group also had an increased incidence of acute graft-versus-host disease of liver (6 vs 1, P = 0.03). However, there was no significant increase in the incidence of veno-occlusive disease (10 vs 7, P = 0.40) and persistent hepatitis (3 vs 0, P = 0.07) in the hepatitis B surface antigen positive group. Using the log-rank test, there was no significant difference in survival between the hepatitis B surface antigen positive and negative recipients.

Knowledge about some of the rarer causes of dementia is now quite advanced (Lautenschlager and Martins, 2005), which can in turn inform other more common causes of dementia. Such is the case with the monogenic disorder of Huntington's disease (HD) when compared to, say, Alzheimer's disease (AD). HD is an autosomal dominant hereditary neurodegenerative disease, which involves the basal ganglia, its connections to the frontal lobe and related neural circuits. The onset of HD is typically in mid-life (but onset can range from childhood to old age), with motor, cognitive and neuropsychiatric symptoms. There is currently no cure for this devastating and inevitably fatal neurodegenerative disease, with current treatment approaches being solely symptomatic. The highest frequencies of HD are found in Europe and in those countries whose populations are of predominately European origin such as the USA and Australia (approximately 1 case per 10,000 people).

Aims: This study examines elements of genetic discrimination among an at-risk, clinically undiagnosed Huntington's disease (HD) population. Methods: Sixty at-risk individuals, either positive or negative for the HD genetic mutation, completed a survey regarding their experiences of genetic discrimination, adverse and unfair treatment, and knowledge about existing laws and policies surrounding genetic discrimination. Results: Sixty eight percent of participants reported feeling “Great benefit” from knowing their genetic test results. Reported benefits of knowledge included planning for the future, making decisions, and many individuals found meaning in active participation in the HD community and in advocating for themselves or families at risk for HD. Many individuals found personal meaning and a sense of community from knowledge of this information and from the ability to participate in research. Despite these positive feelings toward gene testing, results demonstrated that 33% of participants perceived experiences of genetic discrimination, which occurred repeatedly and caused great self-reported distress. Significantly, more gene-positive respondents reported experiencing incidents of genetic discrimination, compared to gene-negative respondents. At least 58 separate incidents of discrimination were reported, the number of incidents ranged from 1 to 10, with 45% of individuals (9/20 respondents) indicating more than one event. Of the most significant events of discrimination, 58% were related to insurance, 21% to employment, 16% to transactions of daily life, and 5% to relationships. Conclusion: Results contribute toward validation of empirical data regarding genetic discrimination.

Thirty-nine Chinese patients presenting as essential thrombocythemia (ET) were analyzed retrospectively. The median age at presentation was 69 years and the M:F ratio was 1.35:1. At diagnosis, 33 cases (84%) were asymptomatic and the diagnosis was made incidentally, while 3 cases (8%) presented with small vessel, and 2 cases (5%) with large vessel, thrombosis. One patient (3%) presented with minor bleeding. The platelet count ranged from 0.9-34 x 10(12)/l. Of 12 karyotypes done, 2 cases were abnormal, both showing the Philadelphia (Ph) chromosome. First-line therapy was radiophosphorus (32P) in 3 cases, melphalan in 20 cases, and hydroxyurea in 12 cases; 4 cases did not receive specific therapy. During the follow-up (mean = 4 years), no thrombotic or bleeding episodes were observed. One patient with the Ph chromosome underwent blastic transformation. These results indicate that bleeding and thrombosis occur significantly less in Chinese patients than in Western patients. The Ph chromosome appears to be a bad prognostic indicator. Because of the very low incidence of complications and good prognosis, the authors believe that cytoreductive therapy is best achieved by the use of hydroxyurea instead of alkylating agents or radiophorphours, as the latter agents are potentially leukemogenic.

Tourette's syndrome is a chronic neurological disorder manifested by involuntary motor tics and vocalisations. Because the basal ganglia have been implicated in the pathology underlying Tourette's syndrome, the present two procedures, both involving sequential movements, sought to determine the extent to which patients with Tourette's syndrome were reliant on, and could utilise different levels of advance information. Patients with Tourette's syndrome were found to be more reliant than controls on external visual cues to execute rather than to initiate a motor programme. When there was a high level of reduction in advance information--that is, a visual pathway to be followed was extinguished well in advance of each successive movement--executions progressively slowed as the sequence was traversed. Similarly, if no advance information was provided before each move, movement execution was slower than that of controls. The movement initiation times of patients with Tourette's syndrome were, however, similar to those of controls, as were their movement execution times when advance visual information was available. It seems that patients with Tourette's syndrome, like parkinsonian patients who are known to have a basal ganglia disorder, require external sensory cues to sequence a motor programme effectively. The present study found evidence consistent with the hypothesis that patients with Tourette's syndrome, like patients with Parkinson's disease, may be dysfunctional in internal switching mechanisms. Alternatively, with limited visual guidance, patients with Tourette's syndrome, regardless of medication or depression state, may require more time to plan and programme each next submovement, and under such conditions may require external visual cues to direct attention effectively to given targets. Although the underlying pathogenesis is still speculative, it is concluded that there is much to support the notion that Tourette's syndrome may stem from abnormalities of the major pathways between the basal ganglia and the frontal lobes.

Purpose of review To undertake a systematic review of articles published in the years 2008-2010 related to medical comorbidities in psychogeriatric patients. This paper addresses selected research findings on the prevalence and causes of medical comorbidity in elderly patients with psychiatric illnesses. MEDLINE, EMBASE and PsychINFO databases were used to identify potential studies. Specific medical comorbidities which were studied included osteoporosis and diabetes. Several studies investigated general medical comorbidities. Recent findings Elderly patients with psychiatric illness generally had the presence of at least one medical comorbidity compared with elderly patients without a psychiatric illness. Depression in elderly patients was the most commonly studied psychiatric illness. Summary Elderly patients with psychiatric illness commonly have comorbid medical conditions. The presence, appropriate investigations and management of these are often suboptimal and can affect quality of life and increase mortality.

Seminested polymerase chain reaction (PCR) was used to amplify the DNA fragments of the complementarity-determining region 3 of the immunoglobulin (Ig) gene heavy chain from the malignant cell specimens of patients with leukemias and lymphomas of B-cell lineage. Two different pairs of primers were used sequentially. Twenty of the 27 (74%) acute lymphoblastic leukemia (ALL) patients, 14 of 19 (74%) chronic lymphocytic leukemia (CLL) patients and eight of 20 (40%) non-Hodgkin's lymphoma (NHL) patients, who had rearrangement of the Ig gene heavy chain by Southern analysis, were positive by the seminested PCR. False-negative results appeared to occur more commonly in cases of lymphoma. The PCR analysis was also less likely to be positive if one-stage PCR studies with either pair of primers were both negative. The seminested PCR technique was found to have a high sensitivity of detecting malignant cells at the level of 0.02%. The clinical application of this assay needs to be investigated further.

Maintenance of motor set in patients with unipolar major depression was examined. Twelve melancholic and 12 non-melancholic depressed patients and 24 age matched controls performed a serial choice reaction time task while external cues aiding maintenance of a motor set were systematically removed. Melancholic patients were significantly slower than controls with no reduction in external cues and with a moderate reduction in external cues. At a high level of reduction in external cues, seven of 12 melancholic patients (but only three of 12 non-melancholic patients and controls) were unable to complete the task; suggesting a greater reliance on external cues, perhaps implicating a failure of motor planning ability in melancholic patients. This, in turn, may point to a prefrontal (premotor) deficit in melancholic depression, with possible commonalities with Parkinson's disease.

Although there is a great emphasis on memory in the diagnosis of dementia and in the measurement of treatment response, disorders of language are an important, but sometimes neglected, feature of many dementias.

Seventeen patients with non-Hodgkin's lymphoma involving the orbit were studied. There were 12 males and 5 females and their median age was 53 years. Three cases were classified as stage I, two as stage II and 12 as stage IV. The histology was small lymphocytic type in 4 of the 5 stage I and II cases, and immunophenotyping, confirming their B-cell origin, was performed in two of these cases. All stage I and II patients responded favourably to local radiotherapy alone. The 12 stage IV patients had a marked male predominance and more commonly an intermediate grade histology and T-immunophenotype. Several of the orbital lesions seemed to represent extension of nasal lymphomas. The stage IV patients had a poorer survival than the stage I and II patients but the difference was not statistically significant, probably due to the small number of patients.

One hundred Chinese patients who received induction cytotoxic therapy for malignant lymphoma were prospectively studied to determine the incidence, morbidity, mortality, and predisposing factors for reactivation of hepatitis B virus replication during cytotoxic therapy. In 18 (67%) hepatitis B surface antigen-positive and 10 (14%) hepatitis B surface antigen-negative patients, hepatitis developed during cytotoxic therapy (P less than 0.0001). Hepatitis could be attributed to exacerbation or reactivation of chronic hepatitis B in 13 (72%) hepatitis B surface antigen-positive patients but in only 2 (20%) hepatitis B surface antigen-negative patients (P less than 0.0001). Sudden increase or reactivation of hepatitis B virus replication gave rise to icteric hepatitis, nonfatal hepatic failure, and death in 22.3%, 3.7%, and 3.7% of patients who were positive for hepatitis B surface antigen; in 2%, 2%, and 0% of those positive for hepatitis B antibodies; and in none of those who were seronegative. Among the hepatitis B surface antigen-positive patients, male sex was the only factor that was associated with an increased risk of reactivation of hepatitis B virus replication. We recommend that hepatitis B surface antigen-positive patients with malignancies receiving cytotoxic therapy be closely monitored.

Sixty cases of nasal lymphomas were reviewed. There were 42 men and 18 women. the median age was 49 years. the histologic types were low grade in four cases, intermediate grade in 33, high grade in seven, and unclassifiable in 16. Thirteen cases had features of polymorphic reticulosis. the immunophenotype was available in 18 cases and a majority of 67% of them were T-cell. Forty-one of them (68%) had clinically localized (Stage I and II) disease which often spread locally to neighboring tissues and they presented predominantly with nasal symptoms. Nasal lymphoma appeared to carry a poor prognosis. Although our patients with clinically localized disease had significantly better prognosis than those with advanced disease, the 5-year survival of Stage I and II patients was only 55%. Chemotherapy did not appear to be more effective than radiotherapy alone in preventing relapses but the patient number was too small to allow a firm conclusion to be made. Patients with advanced disease had even poorer prognosis with a 5-year survival of only 17%. Innovative therapy has to be developed for these patients.

One hundred febrile episodes in 89 neutropenic patients after cytotoxic chemotherapy were randomized to be treated with either ceftazidime or imipenem as initial monotherapy. The clinical characteristics of the two groups of patients were comparable. The response of the fever in patients who received imipenem was significantly better than that in those who received ceftazidime (77 versus 56%, respectively; P = 0.04), especially in those with microbiologically documented infection (81 versus 33%, respectively; P = 0.02). The in vitro susceptibilities and the clinical responses suggested that, with the possible exception of Pseudomonas spp., imipenem was more effective than ceftazidime in treating neutropenic infections caused by both gram-positive and -negative organisms. An additional 23 and 21% of the patients in the ceftazidime and imipenem groups, respectively, responded to the addition of cloxacillin and amikacin following failure of monotherapy. The majority of the treatment failures, relapses, and superinfections were related to resistant infective organisms such as methicillin-resistant Staphylococcus spp. and Pseudomonas spp. or disseminated fungal infections., link_to_subscribed_fulltext

Over half of the world's population lives in Asia. With the Asian population aging, it is predicted that there will be a concomitant rapid rise in the number of people with dementia. Unfortunately, most countries in this region are still not well prepared to provide quality services for people with dementia.

We investigated both motor overflow and ability to control voluntary movement in patients with Huntington's disease (HD). We hypothesised that, compared with controls, overflow would be significantly greater in HD participants and that they would exhibit poorer control of voluntary movement. In a finger flexion task, participants had to maintain target forces representing 25, 50, or 75% of the maximum strength capacity for whichever finger was performing the task; overflow was measured in the corresponding finger of the non-responding hand. HD participants exhibited significantly greater motor overflow than controls, and more difficulty controlling the target force with the active hand. In addition, the degree of overflow in HD participants positively correlated with overall UHDRS motor symptom severity. The presence of exacerbated motor overflow in HD, and its correlation with symptom severity, is an important finding worthy of further investigation.

This issue of International Psychogeriatrics is 96 pages thicker than usual, because it carries not only the International Psychogeriatric Association (IPA) Consensus Statement on Defining and Measuring Treatment Benefits in Dementia, but also a series of papers that were presented at the two-day conference devoted to the development of the consensus statement, which took place in the precincts of Canterbury Cathedral on 31 October and 1 November 2006. During the conference, the delegates (whose names are listed in an appendix to the consensus statement) heard presentations on what outcomes matter to people with dementia and their caregivers, how these can be measured and what they mean, cognitive change as an outcome, biological outcome measures, quality of life, neuropsychiatric symptoms (also known as behavioral and psychological symptoms of dementia (BPSD)), global measures of change, the relevance of different outcome measures to various cultures, activities of daily living, economic outcomes and the regulator perspective. These presentations have been refined into papers and are now published within these pages. In addition to 12 formal presentations on these topics, nine discussants led the conference in exploring the issues raised by the talks, and there was active and often heated debate on almost all the issues discussed. During the afternoon of 1 November agreement was achieved on several key points, which formed the basis for a draft consensus statement prepared the next day. This statement has been refined by a process of circulation among participants, whose suggestions have been incorporated into the document that is now published in this issue.

Objective To determine the difference in outcome among elderly people with major depression who do and do not have severe white matter lesions on magnetic resonance imaging. Design Follow up study. Setting Two psychiatric and two general hospitals in Melbourne, Australia. Subjects 60 depressed subjects aged over 55 referred to hospital psychiatric services with major depressive disorder meeting American Psychiatric Association (DSM-IIIR) criteria. Main outcome measure Proportion with good outcome as determined by full recovery from initial illness and no evidence of depressive relapse or cognitive decline during follow up among those with and without lesions. Results Mean (SD) follow up was 31.9 (9.9) months. Survival analysis showed a significant effect of severe lesions on time to poor outcome (P=0.04), with median survival 136 days in those with severe lesions compared with 315 days in those without. Conclusion Severe white matter change on magnetic resonance imaging is associated with poor outcome in elderly depressed subjects. Key messages Severe deep white matter lesions on magnetic resonance imaging are common in elderly patients with depression Patients with these lesions are at greater risk of poor long term outcome (chronicity and relapse) than those without lesions The neuropathogical and neurochemical correlates of these white matter changes need investigation

Primary nasal T or NK cell lymphoma is rarely seen in the Western population but is more common in the Orientals. Although it often presents with localized disease, the prognosis is generally poor. Long-term remission is seen in only 50% of patients with stage I disease despite aggressive treatment with chemotherapy and radiotherapy, and is invariably fatal if disseminated. Conventional chemotherapy for relapsed disease is usually not successful. Since 1992, three patients with relapsed primary nasal T/NK cell lymphoma have received high-dose chemotherapy with autologous bone marrow rescue at Queen Mary Hospital, Hong Kong. High-dose cyclophosphamide, BCNU and etoposide were used for conditioning. Two of them had a favourable response and remained in complete remission at 12 and 44 months post-transplant. The third patient unfortunately had a systemic relapse 6 months after the transplant. It appears from this experience that, like other aggressive non-Hodgkin's lymphomas, high-dose chemotherapy and autologous bone marrow rescue is an effective treatment for relapsed primary nasal lymphoma following failure of conventional chemotherapy and radiotherapy.

We secured a grant from the Legal Services Board of Victoria to fund a follow-on project from RESPOND-HD to analyze and explore the Australian experience of genetic discrimination (GD), using HD as a case model. The objectives are 1) improving knowledge of laws related to GD, 2) improved legal services, and 3) development of easily accessible resources (brochure, website) informing consumers of their rights. Results Of 60 participants (65% female; 35% male; 60% HD gene positive; 40% gene negative), aged between 20 and 69 years, 32% reported experiencing GD, with mean number of incidences 3.17 (±3.35). Participants experienced discrimination in employment, social, and insurance domains. For example, 17% of respondents had been refused insurance coverage, 20% offered coverage only at a higher premium, 55% told because of family history they could get only limited coverage, and 36% told that due to test results they could get only limited coverage. Responses to Discrimination 1 Action—getting involved in activities 2 Inaction—do nothing, react with positivity, feel surprised by discrimination 3 Involvement—information provision, research involvement 4 Advice—regarding event or potential for event 5 Advocacy—to reduce stereotyping, providing education Awareness of Legislation Victoria's anti-discrimination laws are contained in the Equal Opportunity Act 1995, Disability Discrimination Act 1992, and Human Rights and Equal Opportunity Commission Act 1986. Regarding GD, 17% of participants knew where to make a complaint; 27% knew of laws preventing employers from unfairly using genetic information; 15% knew of laws preventing health insurance companies from accessing or requiring genetic information about an insured person; and 10% knew of laws preventing these companies from using genetic information to deny insurance. We aim to increase these percentages. We are funded to hold focus groups to discuss results and clarify issues with several cohorts (gene-negative participants, gene-positive participants, family members, case workers, health professionals, and researchers), and also for a public launch of the above-mentioned resources.

Background Huntington's disease (HD) is an autosomal dominant progressive neurodegenerative disorder characterized by motor, psychiatric, and cognitive dysfunction. One of the main focuses of clinical research now is to define valid and reliable biomarkers of disease onset and progression that can be of use in future treatment trials. Various neuropathological and neuroimaging studies have indicated early involvement of various components of the basal ganglia. Aim In this study, we examined the sensitivity of three magnetic resonance techniques in detecting basal ganglia pathology. Diffusion tensor imaging (DTI) is an MRI technique that measures indices of passive water diffusion, which is believed to reflect the tissue fiber density, fiber architecture, and uniformity of nerve fiber direction. Proton MRS (1H-MRS) is a non-invasive technique that allows the detection of brain chemicals that contain hydrogen, such as N-Acetyl-aspartate (NAA), choline-containing compounds (CHO), creatine/phosphocreatine (CRE), glutamine, glutamate, myoinositol (mI), and lactate (LAC). Volumetric measures of caudate and putamen can be obtained from structural MRI scans. Method We examined 25 HD gene carriers (13 preclinical and 12 early symptomatic) and 20 matched gene negative controls. The three imaging modalities were performed on each subject using a GE Signa 1.5T scanner during one scan session. Six HD gene carriers and two control subjects were scanned twice, two years apart. Clinical measures were also collected. Results The H-MRS revealed increased choline/creatine and myoinositol/creatine ratios in the basal ganglia in the symptomatic group and decreased glutamate+glutamine/creatine ratios in the preclinical group. Preliminary DTI analyses suggest reduced anisotropy, measured as fractional anisotropy in the basal ganglia. More detailed DTI results and volumetric data will be presented at the meeting. The sensitivity, limitations of, and relationship between the three MRI imaging modalities in detecting basal ganglia pathology in HD will be discussed. The combination of all three techniques may provide a more powerful tool to predict aspects of the clinical presentation.

Polymerase chain reaction (PCR) was used to amplify the DNA fragments of the complementarity determining region 3 of the immunoglobulin (Ig) gene heavy chain from the leukemic cell specimens of patients with acute and chronic lymphoid leukemias of B-cell lineage. Two different pairs of primers were tested. Fourteen of the 17 (82%) cases of acute lymphoblastic leukemia (ALL), and all 15 cases (100%) of B-cell chronic lymphocytic leukemia, who had rearrangement of the Ig gene heavy chain by Southern analysis, were positive by PCR with either one or both pairs of primers. This technique was able to detect leukemic cells at the level of 0.1%. Applying it to study the remission marrow specimens following induction chemotherapy was more useful than morphology alone in predicting early relapse of the leukemia.

Population Ageing will have its greatest impact in the developing world, particularly in the Asian region, with a lower level of “ageing preparedness” to meet this challenge. Each country in this region has traditional and new ways to deliver health and social care for its elderly citizens. For people beyond these countries, ignorance, old perceptions and misunderstanding may colour their views of ageing in these countries. Therefore, Ageing International plans to, with each issue, commission a paper from a country in the region to inform our readership of the challenges and how they are being met and what plans are in place to increase the country’s preparedness in the face of population ageing. The first paper in this series comes from India, a country with rapid population growth as well as a fast growing economy and increasing life expectancy. Future issues will see papers commissioned from China, Japan and Indonesia. Ageing International hopes these papers will open a window through which readers will see and understand ageing in these countries as described by them. Ageing Int. (2008) 32:257 DOI 10.1007/s12126-008-9024-1