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2018 Volume 31 Issue 1
Systematic review and meta-analysis
Adjunctive Peony-Glycyrrhiza decoction for antipsychotic-induced hyperprolactinaemia: A meta-analysis of randomised controlled trials Wei Zheng, Dong-Bin Cai, Hai-Yan Li, Yu-Jie Wu, Chee H Ng, Gabor S Ungvari, Shan-Shan Xie

Background Hyperprolactinaemia is a common adverse effect of antipsychotics (APs). The results of Peony-Glycyrrhiza decoction (PGD) as a potentially useful adjunctive treatment for hyperprolactinaemia are inconsistent.

Aim This meta-analysis of randomised controlled trials (RCTs) examined the efficacy and safety of adjunctive PGD therapy for AP-induced hyperprolactinaemia.

Methods English (PubMed, Embase, Cochrane Library, PsycINFO) and Chinese (Chinese National Knowledge Infrastructure, Wanfang Data) databases were systematically searched up to 10 June 2018. The inclusion criteria were based on PICOSParticipants: adult patients with schizophrenia; Intervention: PGD plus APs; Comparison: APs plus placebo or AP monotherapy; Outcomes: efficacy and safety; Study design: RCTs. The weighted mean difference (WMD) and risk ratio (RR) along with their 95% CIs were calculated using Review Manager (RevMan) V.5.3 software.

Results Five RCTs (n=450) were included and analysed. Two RCTs (n=140) were double-blind and four RCTs (n=409) reported random assignment with specific description. The PGD group showed a significantly lower serum prolactin level at endpoint than the control group (n=380, WMD: 32.69 ng/mL (95% CI 41.66 to 23.72), pI 2=97%). Similarly, the superiority of PGD over the control groups was also found in the improvement of hyperprolactinaemia-related symptoms. No difference was found in the improvement of psychiatric symptoms assessed by the Positive and Negative Syndrome Scale (n=403, WMD: 0.62 (95% CI 2.38 to 1.15), p=0.49, I 2=0%). There were similar rates of all-cause discontinuation (n=330, RR 0.93 (95% CI 0.63 to 1.37), p=0.71, I 2=0%) and adverse drug reactions between the two groups. According to the Grading of Recommendations Assessment, Development and Evaluation approach, the level of evidence of primary and secondary outcomes ranged from very low (14.3%), low (42.8%), moderate (14.3%), to high (28.6%).Conclusions Current evidence supports the adjunctive use of PGD to suppress elevated prolactin and improve prolactin-induced symptoms without significant adverse events in adult patients with AP-induced hyperprolactinaemia. High-quality RCTs with longer duration are needed to confirm these findings. 

Original research article
Development and validation of a screening instrument for cognitive fluctuation in patients with neurocognitive disorder with Lewy bodies (NCDLB): the Mayo Fluctuations Scale-Thai version Papan Thaipisuttikul, Pitchayawadee Chittaropas, Pattaraporn Wisajun and Sudawan Jullagate

Background Prevalence of neurocognitive disorder with Lewy bodies (NCDLB) is low in Asian populations, which may partially reflect its diagnostic difficulty. The Mayo Fluctuations Scale, a short questionnaire that evaluates cognitive fluctuation, has been shown to significantly differentiate NCDLB from Alzheimer’s disease.

Aim This study aimed to develop the Mayo Fluctuations Scale-Thai version and assess its validity to screen NCDLB in an elderly population.

Methods The Mayo Fluctuations Scale was translated into Thai. The process involved back-translation, cross-cultural adaptation, field testing of the prefinal version, as well as final adjustments. From all patients attending the Psychiatric and Memory Clinic at Ramathibodi Hospital, 135 patients accompanied by their primary caregivers were included. Caregivers were interviewed by research assistants using a four-item scale, and psychiatrists determined patients’ diagnosis based on the diagnostic and statistical manual of mental disorders (DSM)-5 criteria. Evaluations performed by psychiatrists and research assistants were blinded.

Results Seventeen participants had been diagnosed with major NCDLB. At a cut-off score of 2 or over, the Mayo Fluctuations Scale exhibited excellent performance to differentiate major NCDLB from other major neurocognitive disorders (NCDs), with a sensitivity of 94.1% and a specificity of 71.4%, and acceptable performance to differentiate mild NCDLB from other mild NCDs, with a sensitivity of 60% and a specificity of 93.1%.

Conclusion The Mayo Fluctuations Scale-Thai version is an excellent screening tool for major NCDLB and an acceptable tool that may be used with other additional tests for mild NCDLB. The tool is practical for use in memory and psychiatric clinics. Further validation studies in participants with other specific clinical conditions are required.

Work-family conflict and job burn-out among Chinese doctors: the mediating role of coping styles Ling Chen, Junjun Liu, Hailong Yang, Hui Ma, Hui Wang, Yun Huang, Hao Cheng, Dianzhen Tang

Background Burn-out among doctors threatens their own health, and that of their patients. To identify risk factors of the doctor burn-out is vital to improving their health and increasing the quality of healthcare services. This study aims to explore the relationship between work-family conflict (WFC) and burn-out among Chinese doctors and the mediating role of coping styles in this relationship.

Methods A cross-sectional survey was conducted in China, with a questionnaire packet which consisted of the Chinese Maslach Burnout Inventory (CMBI), WFC Scale and the Simplified Coping Style Questionnaire (SCSQ). A total of 2530 doctors participated in the survey. Correlation analysis was performed to explore the relationship between CMBI, WFC and SCSQ scores. A linear regression model was set to determine the mediating role of coping styles on the relationship between WFC and burn-out.

Results Doctors who had higher scores on work interfering with family conflict, reported more emotional exhaustion (r=0.514, P

Conclusions WFC was correlated with burn-out, and coping style was a mediator in this relationship among Chinese doctors. Coping style was a positive resource against burn-out.

Regional homogeneity of intrinsic brain activity related to the main alexithymia dimensions Han Dai, Li Mei, Mei Minjun and Sun Xiaofei

Background Alexithymia is a multidimensional personality construct.

Objective This study aims to investigate the neuronal correlates of each alexithymia dimension by examining the regional homogeneity (ReHo) of intrinsic brain activity in a resting situation.

Methods From university freshmen, students with alexithymia and non-alexithymia were recruited. Their alexithymic traits were assessed using the Toronto Alexithymia Scale-20. The ReHo was examined using a resting-state functional MRI approach.

Results This study suggests significant group differences in ReHo in multiple brain regions distributed in the frontal lobe, parietal lobe, temporal lobe, occipital lobe and insular cortex. However, only the ReHo in the insula was positively associated with difficulty identifying feelings, a main dimension of alexithymia. The ReHo in the lingual gyrus, precentral gyrus and postcentral gyrus was positively associated with difficulty describing feelings in participants with alexithymia. Lastly, the ReHo in the right dorsomedial prefrontal cortex (DMPFC_R) was negatively related to the externally oriented thinking style of participants with alexithymia.

Conclusion In conclusion, these results suggest that the main dimensions of alexithymia are correlated with specific brain regions’ function, and the role of the insula, lingual gyrus, precentral gyrus, postcentral gyrus and DMPFC_R in the neuropathology of alexithymia should be further investigated.

Microglia activation in the offspring of prenatal poly I: C exposed rats: a PET Imaging and Immunohistochemistry Study Xue Li, Xin Tian, Luxian Lv, Gangrui Hei, Xufeng Huang, Xiaoduo Fan, Jinming Zhang, Jianjiang Zhang,

Background The well-known ‘pyrotherapy’ of Julius Wagner-Jauregg might be the beginning of the study on the immunological concepts of schizophrenia. As the primary immune effector cells in the brain, microglia play a pivotal role in neuroinflammatory processes. Maternal viral infection during pregnancy is associated with an increased risk for psychiatric disorders with presumed neurodevelopmental origin, including autism spectrum disorders and schizophrenia. The present study was to quantify microglia activation in vivo in the mature offspring of rats exposed to polyriboinosinic–polyribocytidilicacid (Poly I:C) during pregnancy using11C-PK11195 positron emission tomography (PET) and immunohistochemistry.

Objective The study aimed to quantify microglia activation in vivo in the prefrontal cortex and hippocampus in mature offspring of prenatal Poly I:C exposed rats.

Methods Offspring of Poly I:C-treated dams were the model group, offspring of saline-treated dams were the control group. Behavioural test for two groups was taken by spontaneous activity, prepulse inhibition (PPI) and latent inhibition (LI) test (including active avoidance conditioning task and passive avoidance conditioning task). Randomly selected successful model rats were assessed by behavioural test in the model group and control group rats.11C-PK11195 micro-PET/CT and immunohistochemistry were performed on the selected rats to measure microglia activation.

Results The treatment group showed hyperlocomotion and deficits in PPI and LI compared with the control group. The treatment group also showed an increased11C-PK11195 uptake ratio in the prefrontal cortex (t=−3.990, p=0.003) and hippocampus (t=−4.462, p=0.001). The number of activated microglia cells was significantly higher in the treatment group than in the control group (hippocampus: t=8.204, pt=6.995, p

Conclusions The present study demonstrated microglia activation in vivo in the prefrontal cortex and hippocampus in mature offspring of prenatal Poly I:C exposed rats. This study suggests that microglia activation may play a possible or potential role in the pathogenesis of schizophrenia.

Forum
Precise treatments for schizophrenia: where is the way forward? Chen Zhang, Yemeng Mao and Lisheng Song
Editorial
New journey, New mission: Bolstering International Communication about Mental Health Yifeng Xu
Case report
Switch from previous major depression comorbid with CLIPPERS to mania-like episode following glucocorticosteroid therapy: a case report Xiaohua Liu and Yan Wu Bipolar disorder is associated with high rates of general medical conditions, but few cases of overlap between bipolar disorder and chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) have been reported in the current literature. The following is a case of a 29-year-old patient with a previous major depressive episode comorbid with CLIPPERS. Following glucocorticosteroid therapy, the patient switched to mania-like presentation and was diagnosed with bipolar disorder due to another medical condition. So it is strongly suggested that high-dose corticosteroid pulse therapy could easily induce psychiatric disturbances for patients with previous psychiatric symptoms, and there may be potential links between bipolar disorder and CLIPPERS in the area of inflammation.
Psychosis as an indicator of recurrent non-Hodgkin’s lymphoma: a rare presentation Mustafa Ali and Soumitra Das Psychotic manifestations of brain tumours are rare but described in the literature mostly along with other neurological deficits. Memory loss, difficulty in attention and concentration, depression, anxiety, and mood symptoms are commonly described in brain tumours. A schizophrenia-like picture without a deficit in motor or sensory function may land the clinician into a diagnostic dilemma. Primary central nervous system lymphoma (PCNSL) is a highly malignant disease with high mortality and needs immediate attention. Our case which had a unique recurrence in the postoperative period with psychotic symptoms can be an eye-opener to be more vigilant about underlying clinical extension.
Biostatistics in psychiatry
Tests for paired count outcomes James A Proudfoot, Tuo Lin, Bokai Wang and Xin M Tu For moderate to large sample sizes, all tests yielded pvalues close to the nominal, except when models were misspecified. The signed-rank test generally had the lowest power. Within the current context of count outcomes, the signed-rank test shows subpar power when compared with tests that are contrasted based on full data, such as the GEE. Parametric models for count outcomes such as the GLMM with a Poisson for marginal count outcomes are quite sensitive to departures from assumed parametric models. There is some small bias for all the asymptotic tests, that is,the signed-ranktest, GLMM and GEE, especially for small sample sizes. Resampling methods such as permutation can help alleviate this.