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Prevalence of Organic Mental Disorders in a General Hospital in Izhevsk, Russia| Lupine Publishers

Journal of Neurology & Neurosurgery- Lupine Publishers

Abstract

Background and Objectives: At the moment, studies of organic mental disorders (OMD) in in-patients of therapeutic units in Udmurtia are limited. The paper’s objective was to study the prevalence and risk factors of OMD in medical patients in one of the municipal hospitals of Izhevsk.
Methods: The subjects (323 patients aged from 18 to 59 years) were selected using the method of continuous sampling. All subjects were asked to answer the questions from the Russian version of the Brief International Neuropsychiatric Questionnaire (MINI 5.0.0.).
Results: The prevalence of OMD was 55.1%. OMD were more common in older patients (50-59 years) and in patients with chronic somatic diseases. 36.5% of patients with OMD were diagnosed with pre-dementia. The comorbidity of OMD with other mental disorders was statistically significant for depression and anxiety disorders.
Conclusion: Knowledge of OMD risk factors can contribute to early detection and adequate treatment of OMD in patients of general hospitals.
Keywords: Organic mental disorders; Prevalence; risk factors; General hospital

Background and objectives

According to scientific literature, the prevalence of organic mental disorders (OMD) in patients with somatic diseases is high [1-5]. Researchers note that OMD, along with depression and alcoholism, are the most frequent comorbid psychiatric disorders in therapeutic and surgical units [6-9]. Despite high epidemiological indicators, most of OMD in general hospitals are not recognized and not treated [6]. The consequence of comorbid OMD underdiagnosis is worsening of somatic pathology, increased resistance to therapy, and increased risk of disability [10]. OMD significantly impair social functioning and the quality of life [11]. It has been found that the degree of cognitive function deterioration in patients has a positive correlation with the duration of hospitalization and the cost of treatment [12-14].
Researchers emphasize that early, even immediate detection of organic mental disorders is extremely important [6]. At the moment, studies of organic mental disorders (OMD) in in-patients of therapeutic units in Udmurtia are limited. The paper’s objective was to study the prevalence and risk factors of OMD in medical patients and identify correlative factors.

Methods

The research was carried out in Izhevsk, the capital of the Udmurt Republic, Russia, in therapeutic unit 1 of City Hospital No. 5. The hospital had two therapeutic units. Therapeutic unit 1 (65 beds) was intended for prearranged and emergency hospitalization of the working-age and retired patients from the district the hospital is formally assigned to serve (with an adult population of 57,000 people, about 70% of whom are working age). Therapeutic unit 2 was intended for the population with the official status of ‘participants and disabled veterans of the Great Patriotic War’ (note – Russian name for World War II) and equivalent categories of patients from Izhevsk. The average annual number of patients hospitalized to the first unit was 1,220 people, more than a half of them aged 50 and older.
The subjects were selected using the method of continuous sampling. The group included every patient aged 18 to 59 referred to the hospital unit number 1. The average length of hospitalization per patient was 18.3 days. A total of 352 patients were selected for the study. 29 of them (11 men and 18 women) were not included in the study for various reasons (refusal, severe somatic condition, etc.). Consequently, the study sample consisted of 323 patients, including 147 (45.5%) men and 176 (54.5%) women. Ethnic background of the study population: 214 (66.3%) Russians, 77 (23.8) Udmurts and 32 (9.9%) other. All participants were divided into the following age groups: 18-39 years– 37%, 40-49 years– 31% and 50-59 years– 32%. 71.5% of the study population were hospitalized due to exacerbation of a chronic somatic disease and 28.5% – due to an acute somatic disease.
All subjects were asked to answer the questions from the Russian version of the Brief International Neuropsychiatric Questionnaire (MINI 5.0.0.) [15]. Additionally, the survey used the diagnostic criteria of ICD-10 for organic mental disorders and the criteria for tobacco addiction. MINI is a standardized diagnostic interview for major mental disorders according to DSM-IV and ICD-10. The reliability and validity of MINI correspond to SCID-P and CIDI, but an important advantage of MINI is that interviewing requires less time.
Information on somatic diagnoses, psychiatric consultations and prescribed psychotropic medications was obtained from medical records (medical history, patient records). Socio-demographic questions (gender, age, marital status, ethnic background, education and occupation) are part of MINI. Participation in the study was voluntary; the patients were informed of their right to refuse to participate. In case of consent, complete anonymity was guaranteed. The patients have signed a written ‘Informed Consent’.
Questioning and interviewing in each case were conducted during the first 72 hours of hospitalization. The diagnostic survey was conducted by three medical doctors who had been trained to use MINI at the Department of Psychiatry of Izhevsk State Medical Academy. The STATISTICA 5.0 software was used to analyze the data. The following tests were used: the t-test to compare average values (average monthly income, average age, etc.) and the chisquare test to assess qualitative characteristics (gender, ethnic background, social status, etc.). To analyze comorbidity, the software Epi Info, Version 6 [16] was used. The OMD comorbidity was determined as follows: the probability index of concomitant disease in the population with OMD was divided by the probability index of concomitant disease in the population without OMD. The manuscript has been assessed by the Ethics Committee (Institutional Board Review) in the Izhevsk State Medical Academy.

Results

A. Table 1 Shows a Breakdown of Diagnoses in the Study Population:

Table 1: Somatic diseases and concomitant OMD.

* In case of concomitant somatic diseases, only the principle diagnosis was considered.
Acute diseases predominated in the group of patients with respiratory system disorders – 58.8%, and disorders of other organs and systems were mainly represented by chronic diseases (genitourinary system– 78.3%, digestive system– 78.8%, cardiovascular– 94.8%, and musculoskeletal– 100%). Acute diseases were more often diagnosed in patients aged 18-39 (55.8%), while chronic forms predominated in the age groups of 40-49 and 50-59 years – 77.2% and 98.0% respectively. OMD were more often diagnosed in patients with chronic somatic diseases, especially those with diseases of the circulatory and musculoskeletal systems – 100% of the cases (Table 2).

Table 2: Most common somatic diseases with concomitant OMD.

The OMD prevalence in the sample was 55.1% (178 cases). The average age of the respondents with OMD was 46.6 years (Std. Dev. = 10.2). The average OMD duration was 6.4 years, with the minimum less than one year and the maximum of 45 years (Std. Dev. = 6.4).

B. The Breakdown of OMD is Given Below (Table 3):

Table 3: Organic disorders.

In terms of socio-demographic factors, a reliable correlation with the age of the patients was identified: OMD in the age groups of 18-39, 40-49 and 50-59 years were diagnosed in 19.7%, 33.2% and 47.2% of the cases respectively (P = 0.000). There was no statistically significant correlation between OMD and ethnic background, marital status, education or social status. The tendency to a greater predisposition to OMD in women (56.7% versus 43.3% in men) was identified. There were other psychiatric disorders diagnosed in the sample: depressive disorders – 20.7%, alcohol dependence–24.8%, tobacco dependence – 45.2%, social phobias – 13.3%, other anxiety disorders - 6.5% (ICD-10 codes: F40.01, F41.0, F41.1, F42.8). The comorbidity of OMD with other mental disorders was statistically significant for depression and anxiety disorders (Table 4). 20.2% of patients with OMD were counseled by a psychiatrist.

Table 4: OMD comorbidity with other mental disorders.

Discussion and Conclusion

According to numerous Russian and foreign studies, it has been proven that there are strong structural links between comorbid organic mental disorders and somatic disorders [1] - this fact was confirmed in our study. More than a half of the sample in this study had OMD (55.1%). The most common OMD diagnosis was organic asthenic disorder (51.1% of all OMD). 36.5% of the respondents with OMD had decreased cognitive functions – pre-dementia, and 2.8% were diagnosed with dementia. It is noteworthy that a lot of respondents in the sample (most of whom were at their working age) were diagnosed with pre-dementia or, as it is called in some sources, mild cognitive impairment (MCI) [17]. According to different data, the prevalence of the MCI syndrome among elderly and senile patients (65 years and older) varies from 7% to 38%. It is known there is an increased risk of the MCI syndrome transition to dementia within the next 3 to 5 years [18]. According to a group of researchers from New York University, 42% of people initially diagnosed with the MCI syndrome were diagnosed with dementia in 5 years with only 7% of the patients being in the age-norm group [19].
The researchers emphasize it is not a somatic pathology but its severity and duration that play a role in the development of OMD. Apparently this is why OMD were statistically more often diagnosed in patients with chronic rather than acute somatic diseases (70.1% vs 17.4%). Moreover, 100% of the respondents with diseases of the circulatory or musculoskeletal systems were diagnosed with OMD. High occurrence of OMD was observed among patients with diseases of the digestive and respiratory systems – 90.6% and 77.8% respectively.
There was no correlation between OMD and such sociodemographic factors as gender, ethnicity, marital status, education or social status. There was a reliable correlation between OMD and the age of the patients, probably because of the greater occurrence of chronic somatic diseases and accumulation of cerebrovascular diseases in elderly patients [4]. Thus, the epidemiological indicators of OMD in the general hospital were extremely high, especially among patients with chronic diseases. One third of patients with OMD were diagnosed with mild cognitive impairment, and according to medical sources, there is a high risk that this condition may transform into dementia in the next few years.
Such results may indicate insufficient diagnostics and lack of OMD treatment. The reasons for the under-diagnosis may be insufficient psychiatric care in hospitals and lack of awareness among therapists of the OMD clinical picture. Awareness of epidemiology and risk factors can contribute to early detection and treatment of OMD. Identification and appropriate treatment of OMD is an extremely important task due to the unfavorable prognosis.

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Isolated and Recurrent Peripheral Facial Palsy Revealing Primary Sjogren’s Syndrome

Journal of Neurology & Neurosurgery- Lupine Publishers

 

 

Abstract

Peripheral facial palsy (PFP) is often idiopathic; a secondary systemic cause is noted in less than 1.2% of cases. Primary Sjogren’s Syndrome (PSS) remains an exceptional and often insufficiently known etiology of facial paralysis, and only a few sporadic cases are reported in the medical literature. These inaugural forms of the disease represent a real diagnostic challenge for clinicians. We report an original observation of isolated and recurrent PFP as inaugural symptom of PSS in a 53-year-old female with no notable pathological history.
Keywords: Peripheral facial palsy; Primary Sjögren’s syndrome; Facial paralysis; Neuro Sjogren

Introduction

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Primary Sjögren’s syndrome (PSS) is an autoimmune disease characterized by focal lymphoid infiltration of the exocrine glands, mainly manifested by dry ocular and oral syndrome [1]. During the course of the disease, one-third of the patients develop extraglandular lesions: pulmonary, neurological, renal, hepatic and cardiac, which signal the systemic nature of this disease and condition its prognosis [2,3]. The prevalence of this connective tissue disease is estimated at 1-3% of the general population [1,4] and can reach as much as 4.8% in Europe [2]. The neurological manifestations of this disease are observed in 15-20% of cases and are highly polymorphic and far dominated by peripheral neuropathy [5-8].
The spectrum of PSS-associated neurological manifestations may include: multiple mononeuropathy, symmetrical axonal sensorimotor polyneuropathy, sensory ataxic neuropathy, painful sensory neuropathy, cranial neuropathy, autonomic neuropathy, radiculoneuropathy, aseptic meningitis, encephalopathy, psychiatric symptoms, chorea, seizures, chronic myelopathies, multiple sclerosis-like syndrome, and cognitive impairment [5-8]. Neurological involvement may be the first manifestation of PSS in approximately 25% of cases [7]. Of all the possible neurological manifestations of PSS, peripheral facial palsy (PFP) remains exceptional and unusual [9], and only a few sporadic cases were reported in the medical literature [9-12]; these inaugural forms of the disease represent a real diagnostic challenge for clinicians. We report an original observation of isolated and recurrent PFP as inaugural symptom of PSS.

Case Report

A 53-year-old Tunisian patient, with no notable pathological history, was referred to our department for recurrent PFP. She was treated by her family doctor for three episodes of PFP occurring within a year and a half without any other associated abnormalities. This PFP was right in two times and left in one time. The etiological investigations requested by his treating physician, including a specialized ENT examination and a cerebral CT-scan, were without abnormalities. The diagnosis of idiopathic PFP (Bell’s palsy) was retained. The patient was treated with short course corticosteroid and vitamin therapy but without improvement.
In somatic examination, the patient was apyretic, with correct conscious, respiratory, and hemodynamic status. We noted a marked dryness of the skin and the tongue.
Laboratory tests revealed a marked biological inflammatory syndrome with erythrocyte sedimentation rate at 68 mm/H1, C-reactive protein at 18 mg/l, and polyclonal hypergammaglobulinemia at 24.6 mmol/l. the other basic tests were within normal limits: blood count, creatinine, serum calcium, ionogram, fasting glucose, transaminases, muscle enzymes, lipid parameters, and thyroid hormones. Immunological exploration showed positive anti-nuclear autoantibodies at 1/640 with positive anti-SSA antibodies at 50 IU. The specialized ophthalmologic examination objectified xerophthalmia with bilateral filamentous keratitis and a positive Schirmer’s test.
Biopsy of the accessory salivary glands showed a stage 3 chronic sialadenitis according to the Chisholm classification. Thus, the diagnosis of PSS was retained based on the following criteria: xerophthalmia, xerostomia, positive ophthalmological tests, stage 3 chronic sialadenitis, and positive anti-nuclear and anti-SSA antibodies. Cerebrospinal fluid analysis and cerebromedullary MRI did not show signs suggestive of specific neurological involvement of PSS (neuro-Sjögren). Similarly, other systemic complications of PSS and a possible lymphomatous transformation were eliminated by specific investigations. At the end of this assessment, the diagnosis of a recurrent and isolated PFP revealing PSS was retained. The patient was treated with systemic corticosteroid therapy at a dose of 1 mg/kg/day and hydroxychloroquine at a dose of 400 mg/d, salicylic acid at a dose of 100 mg/d, and symptomatic treatment of xerophthalmia and xerostomia, with favorable evolution. No recurrence of the PFP has been noted for five years now.

Discussion

PFP is often idiopathic (Bell’s palsy or FRP); a secondary systemic cause is noted in less than 1.2% of cases [13]. PSS remains an exceptional [11] and often insufficiently known etiology of facial paralysis [11,14]. Indeed, only a few sporadic cases have been reported in the literature [9-12,15]. In large series of PSS, this neurological manifestation remains unusual: in fact, only two cases of PFP associated with PSS were found in the series of Teixieira F et al of 93 patients followed for PSS [14], no case has was noted in the European series of 392 patients with PSS of whom 74 had neuro-Sjögren’s [8], and no case of PFP was reported in the Ye W et al series of 566 patients with PSS of whom 184 had neurological signs [6]. PSS-associated PFP can be uni- or bi-lateral [12], episodic or most often recurrent [11], isolated or more often integrated in the framework of a complex neurological attack [11] and can remain for a long time the only manifestation of the disease [11,15]. PFP associated with PSS usually responds well to systemic corticosteroids and others specific therapies for this autoimmune disease.
These forms of isolated and SSP-revealing cranial neuropathies are often ignored and neglected by clinicians, and thus sometimes responsible for a very important diagnosis delay [16]. The exact pathophysiology of this neuropathy is not very well known. It appears to be multifactorial involving vasculitis, autoimmunity, inflammation, and cryoglobulinemia [4,5]. A reported case of PSSassociated PFP involved, in addition to these classic pathogenic factors, a vitamin B12 deficiency [11]. Finally, it should be kept in mind that a PFP for rapid onset and/or progression during PSS should raise concerns about the lymphomatous transformation of this disease [17].

Conclusion

Peripheral facial palsy is an exceptional and uncommon neurologic complication of PSS. The isolated and inaugural forms are often ignored by health practitioners and represent a real diagnostic challenge. It is thus necessary to evoke the diagnosis of PSS in front of any PFP that does not proven, particularly if recurrent and in elderly. Early diagnosis and adequate management can improve the prognosis of this disease, especially that a lymphomatous transformation can be announced by a PFP arising and/or progressing rapidly.
 

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