Prospective, open study of long-acting injected risperidone versus oral antipsychotics in 88 chronically psychotic patients

INTRODUCTION

A long-acting, injected, carbohydrate-microsphere preparation of risperidone (RLAI; Risperdal Consta ((R))) is reported to be safe and effective in chronic psychotic illnesses but, as its long-term and comparative efficacy remain unclear, this study compared clinical status during oral antipsychotic treatment versus conversion to RLAI.

METHODS

Psychotic patients (n=88; initial BPRS=93+/-5) were treated for 6 months with clinically chosen oral medication and then converted to biweekly RLAI for the first 6 months (6-6 months matched mirror comparison) and then for another 18 months. Clinical status in the two treatment periods and in the 18 months of follow-up was compared with measures including BPRS improvement (primary outcome), CGI variants and SF-36 ratings.

RESULTS

RLAI (at a mean dose of 47 mg/2 weeks at six and up to 23.1+/-3.3 months) was associated with major improvements in all outcome measures (p<0.001). Initial BPRS scores fell by an average of 50% within six months; hospitalizations declined from 19.8% to 0%, and rates of adverse events were reduced by 2.5- to 7.4-fold. Such benefits were sustained during 18 months of follow-up with RLAI-treatment.

CONCLUSIONS

The findings are limited by the lack of a parallel control treatment, such as with oral risperidone or another antipsychotic, lack of blinded assessments, and a moderate number of subjects. Nevertheless, the findings add to indications that RLAI can be an effective and well-tolerated treatment-option for chronically psychotic patients.

White matter hyperintensities, suicide risk and late-onset affective disorders: an overview of the current literature

White matter hyperintensities (WMHs) refer to areas of hyperintense signal on T2- or proton density-weighted brain magnetic resonance imaging. Although WMHs are a common finding in patients with bipolar disorder (BD), particularly with a later disease onset, some studies report a higher frequency of WMHs only in unipolar affective disorders. We reviewed the literature examining examining both the severity and presence of WMHs in late life and particularly in individuals with late-onset BD (LOBD). Studies investigating white matter lesions in LOBD were systematically retrieved and the reference lists of these studies were scanned for additional relevant studies of neuroimaging in LOBD. The majority of neuroimaging studies reported an association between older age and LOBD and the presence of WMHs in LOBD. Also, we found in a small sample of patients preliminary evidence of a significant relationship between older age with late-onset BD and WMHs having a higher prevalence of cardiovascular and cerebrovascular risk factors. In conclusion over 60 years older individuals with LOBD and WMHs might have a type of illness characterized by more neuropathological changes and biologically different compared to non LOBD. This is consistent with the hypothesis of vascular mania. WMHs could be a reliable biological risk marker for late onset mood disorders.

Duloxetine versus venlafaxine in the treatment of unipolar and bipolar depression

OBJECTIVES

Both duloxetine and venlafaxine are efficacious in treating patients with Major Depressive Disorder (MDD), even though the advantages in treatment patients with bipolar disorder is unclear. This study aimed to evaluate the efficacy of duloxetine vs venlafaxine in the acute treatment of unipolar and bipolar depression.

MATERIALS AND METHODS

The study was a non randomized controlled trial. The participants were 62 consecutive outpatients (41 men; 21 women) affected by unipolar and bipolar depression treated either with duloxetine and venlafaxine.

RESULTS

More patients treated with duloxetine had a positive response to treatment and remission both for depression (HAMD17 response: 90.3% vs 0.0%; p < .001; HAM-D17 remission: 48.4% vs 0.0%; p < .001), and anxiety (HAM-A response: 90.3% vs 6.5%; p < .001; HAM-A remission: 71.0% vs 6.5%; p < .001) than controls. Patients treated with duloxetine were also more likely to show a decrease in HAM-D17 suicidality (100% vs 45.2%; p less than .001) and an increase in the quality of life (SF-36 percentage of improvement: 6.35 [SD=9.66 vs -2.58 [9.98]; p less than .001) than controls.

CONCLUSIONS

Duloxetine is more effective in reducing anxiety and suicidal ideation. Both treatments were safe and tolerated, and both may be successfully used in unipolar and bipolar depression.

Three-dimensional sonohysterography for examination of the uterine cavity in women with abnormal uterine bleeding: Preliminary findings

INTRODUCTION

To compare the diagnostic values of three-dimensional sonohysterography (3DSH), transvaginal ultrasound (TVUS), and 2-dimensional sonohysterography (2DSH) in the work-up of abnormal uterine bleeding (AUB), in particular the ability of each method to identify intracavitary lesions arising from the endometrium or uterine wall.

MATERIALS AND METHODS

24 patients referred for AUB underwent TVUS followed by 2-D and 3-D HS in the same session. Three-dimensional data were acquired with a free-hand technique during maximal distention of the uterus. Within 10 days of the sonographic session, each patient underwent hysteroscopy, which was considered the reference standard. For each of the 3 imaging methods, we calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy.

RESULTS

Hysteroscopy demonstrated the presence of an intrauterine lesion in 21/24 patients (87.5%). In 3/24 patients hysteroscopy was negative. For TVUS, 2DSH, and 3DSH, sensitivity was 76% (16/21), 90% (19/21), 100% (21/21), respectively; specificity was 100% (3/3), 100% (19/19), 100% (21/21); PPV was 100%, 100%, 100%; NPV was 37%, 60%, 100%; accuracy was 76%, 90%, 100%.

CONCLUSIONS

3DSH is more sensitive that 2DSH or TVUS in the detection of intrauterine lesions. If these preliminary results are confirmed in larger studies, 3DSH could be proposed as a valuable alternative to diagnostic hysteroscopy.

Expression and characterization of the periplasmic cobalamin-binding protein of Photobacterium damselae subsp. piscicida

Abstract Cobalamin (vitamin B(12)) is an essential cofactor in a variety of enzymatic reactions and most prokaryotes contain transport systems to import vitamin B(12). A gene coding for a periplasmic cobalamin-binding protein of Photobacterium damselae subsp. piscicida was identified by in silico analysis of sequences from a genomic library. The open reading frame was composed of 834 bp encoding a protein of 277 amino acids. The protein showed 61% identity with the vitamin B(12)-binding protein precursor of P. profundum, 53% identity with the corresponding protein of Vibrio parahaemolyticus and 43% identity with the periplasmic binding protein BtuF of Escherichia coli. The expression of the native protein was investigated in P. damselae subsp. piscicida, but BtuF was weakly expressed under normal conditions. To characterize the BtuF of P. damselae subsp. piscicida, the recombinant protein was expressed with a C-terminal His(6)-tag and purified; the molecular weight was estimated to be approximately 30 kDa. The protein does not contain any free thiol group, consistent with the view that the two cysteine residues are involved in a disulphide bond. The purified BtuF binds cyanocobalamin with an affinity constant of 6 +/- 2 microm.

Rotator cuff calcific tendonitis: short-term and 10-year outcomes after two-needle us-guided percutaneous treatment--nonrandomized controlled trial

PURPOSE

To compare short- and long-term outcomes of patients with rotator cuff calcific tendonitis who did and did not undergo ultrasonographically (US)-guided percutaneous treatment.

MATERIALS AND METHODS

Institutional review board approval and informed patient consent were obtained. Of patients referred for US-guided treatment of rotator cuff calcific tendonitis, 219 (86 men, 133 women; mean age, 40.3 years +/- 10.9 [standard deviation]) were treated; 68 (31 men, 37 women; mean age, 40.2 years +/- 11.3) patients refused treatment and served as control subjects. After local anesthesia was induced, two 16-gauge needles were inserted into the calcific deposit. Saline solution was injected through one needle, and the dissolved calcium was extracted through the other needle. Shoulder joint function was assessed by using Constant scores, and pain was assessed by using visual analogue scale (VAS) scores. Mann-Whitney U and chi(2) tests were performed.

RESULTS

At baseline, no significant difference in age or sex distribution, Constant score, or VAS score was detected between treated and nontreated (control) patients. Compared with control subjects, treated patients reported a significant decrease in symptoms at 1 month (mean Constant score, 73.2 +/- 6.2 vs 57.5 +/- 3.9; mean VAS score, 4.8 +/- 0.6 vs 9.1 +/- 0.5), 3 months (mean Constant score, 90.2 +/- 2.6 vs 62.6 +/- 7.2; mean VAS score, 3.3 +/- 0.4 vs 7.3 +/- 1.8), and 1 year (mean Constant score, 91.7 +/- 3.1 vs 78.4 +/- 9.5; mean VAS score, 2.7 +/- 0.5 vs 4.5 +/- 0.9) (P < .001). Symptom scores were not significantly different between the groups at 5 years (mean Constant score, 90.9 +/- 3.6 vs 90.5 +/- 4.8; mean VAS score, 2.6 +/- 0.5 vs 2.8 +/- 0.7) (P >or= .795) and 10 years (mean Constant score, 91.8 +/- 5.0 vs 91.3 +/- 9.6; mean VAS score, 2.5 +/- 0.6 vs 2.7 +/- 0.6) (P >or= .413).

CONCLUSION

US-guided percutaneous treatment facilitated prompt shoulder function recovery and pain relief. Treated patients had better outcomes than did nontreated patients at 1 year. However, 5 and 10 years after the procedure, the nontreated group reported outcomes similar to those of the treated group.

Contrast-enhanced ultrasound (CEUS) assessment of superselective uterine fibroid embolization (SUFE): Preliminary experience()

PURPOSE

The use of superselective uterine fibroid embolization (SUFE) requires imaging techniques that can be used to verify the success of the procedure. The purpose of our study was to analyze the potential value of pre- and post-treatment contrast-enhanced ultrasonography (CEUS) for assessing the outcome of SUFE and for posttreatment follow-up.

MATERIALS AND METHODS

We studied twelve women undergoing SUFE for uterine fibroids. In those with multiple fibroids, only the three largest were considered in this study. A total of 21 lesions (size range 3.5-9.0 cm, mean 5.2 cm) were examined. Each myoma was examined immediately before and after SUFE (while the patient was still in the angiography room) with transabdominal CEUS performed after intravenous administration of a single bolus of contrast agent. The follow-up protocol included CEUS evaluation one month after treatment and CEUS plus dynamic magnetic resonance (MR) studies six months after treatment.

RESULTS

In 20/21 cases, postembolization CEUS revealed total fibroid devascularization. The remaining lesion (in a woman with multiple lesions) showed persistent vascularization after SUFE. These findings were all consistent with angiographic data. No recurrences were observed during the six-month follow-up. One patient reported the reappearance of symptoms 18 months after SUFE, and CEUS showed the persistence of intralesional vascularization.

CONCLUSIONS

CEUS is effective for assessing the completeness of vascular occlusion following SUFE for uterine fibroids. CEUS findings correlate with clinical results observed one and six months after treatment. Compared with dynamic MR, CEUS is reliable and cost-effective.

Ultrasound-guided injection of botulinum toxin A in the treatment of iliopsoas spasticity

PURPOSE

Intramuscular injection of botulinum toxin A (BTX-A) is a common treatment for iliopsoas muscle spasticity, but it is not easy to position the needle in this muscle without guidance. In this paper we describe an ultrasound-guided technique for the intramuscular injection of BTX-A to treat spasticity of the iliopsoas muscle. Its effectiveness was assessed in 10 patients.

METHOD AND MATERIALS

The ultrasound-guided technique for BTX-A injection was used on 10 patients. The needle was inserted into the muscle belly at an angle of 45° along the longitudinal axis of the muscle when allowed by patient's condition.

RESULTS

In all cases, the iliopsoas muscle was easily identified and both the iliac and psoas components were assessed. Introduction of the needle and drug injection were entirely carried out under ultrasonographic guidance. The procedure was successful in all patients, even in those with a high-grade spasticity, and general anesthesia was not required.

CONCLUSIONS

This ultrasound-guided technique allows accurate guidance for the injection of BTX-A, and it can be considered as an alternate supportive therapy in patients with spasticity and dystonia.

Laparoscopic Treatment of Morgagni-Larrey Hernia: Technical Details and Report of a Series

Three patients with Morgagni-Larrey hernia were admitted to the surgical department between August 2000 and September 2003 with slight chest pain and dyspnea. Laparoscopic repair of the diaphragmatic hernia was performed using a tension-free closure of the defects with either Vicryl-Prolene or dual facing mesh fixed by Prolene extracorporeal knots and Endostitch devices. The patients were discharged on postoperative day 5 without complications. Mean follow-up has been 23 months (range, 15-36 months) and no recurrence or morbidity related to the procedure has been seen. Laparoscopic repair of Morgagni-Larrey hernia represents an attractive alternative to open surgery. The benefits are gentle and easy manipulation of the content of the sac, reduced surgical trauma, and rapid and uneventful recovery.

Anesthesia for MRI in the paediatric patient

The magnetic resonance imaging suite is a challenging environment for the anaesthesiologists, and carries inherent risks. Several factors account for this, including the remote location, the unique features of the magnetic resonance imaging scanner and patient-related factors. A systematic approach, similar to that of anesthesia provided in the operating room (i.e. proper fasting, informed consent, focused airway examination, medical and surgical history, family history, previous sedation experiences) is mandatory. Understanding the implications of the magnetic resonance imaging environment will facilitate ensuring the safety of the patient. A well-equipped anesthesia machine, standard monitoring (electrocardiogram, oxygen saturation and non-invasive blood pressure), trained personnel and adequate planning should be standard for all out of the operating room procedures. Finally, rigorous discharge criteria are recommended to detect residual sedation.

Color Doppler US of the Postoperative Penis: Anatomy and Surgical Complications

A number of surgical procedures that significantly change the penile anatomy and vasculature can be used to manage pathologic conditions of the penis (eg, congenital and acquired deformities, erectile dysfunction, priapism). Phallic reconstruction surgery can be used for sex reassignment and after penile amputation or for correction of congenital malformations. Color Doppler ultrasonography (US) clearly depicts the normal penile anatomy and postoperative changes (eg, changes of the tunica albuginea, extraalbugineal pathologic fluid collections, cavernosal tissue changes produced by scars and fibrosis). It is also effective in evaluating surgery-related complications and determining the causes of erectile dysfunction and other unsatisfactory long-term results. Moreover, color Doppler US of the penile vessels and vascular anastomoses following revascularization allows direct evaluation of flow characteristics, shunt patency, and venous engorgement. Color Doppler US is the imaging modality of choice in evaluating patients who have undergone penile surgery.

Radiofrequency ablation of liver tumours with transpleurodiaphragmatic access

Radiofrequency thermoablation (RFA) is used to treat unresectable liver tumours. RFA is performed using an abdominal access (laparotomic, laparoscopic and percutaneous). A transpleurodiaphragmatic approach has recently been proposed, particularly for the treatment of tumours which are placed near to inferior vein cava and hepatic veins and which are difficult to reach for an abdominal access. A patient with a liver metastasis of the segment VIII underwent RFA with an associated wedge resection of the segment VII, both were performed with a transthoracic access. Peri- and postoperative complications did not occurred. The patient was discharged on fifth postoperative day, and she is disease free after a follow up of 6 months. A transpleurodiaphragmatic access can be considered a safe and efficacy procedure to perform an RFA of a liver tumour in selected cases.

Primary and secondary malignancies of the penis: ultrasound features

Cancer of the penis is a rare neoplasm in developed countries but worldwide represents a significant health problem. In this study, the ultrasonographic features of primary and secondary malignant lesions of the penis are described. Squamous cell carcinoma usually presents as a hypoechoic lesion with heterogeneous appearance. Invasions of the corpora cavernosa and the corpus spongiosum are appreciable. B-cell lymphoma presents as well-vascularized mass, a plaque, or ulcers in the penile skin. Penile metastases results from hematogenous or lymphatic spreading of distant tumors or, more frequently, as penile infiltration by tumors from adjacent organs. Diffuse corporeal or nodular involvement can result.

Radiofrequency-assisted liver resection

Radiofrequency (RF)-assisted thermal ablation has been used with increasing frequency for unresectable hepatic tumors. This new approach employs RF energy to coagulate the liver at the hepatic resection line after which hepatic resection is performed with the use of a common scalpel. This procedure was used in three patients with hepatocellular carcinoma and in five patients with colorectal metastasis to the liver. These eight patients underwent a total of two left bisegmentectomies, three segmentectomies, and seven wedge resections. Mean operative time was 220 minutes. A mean of 78 sessions of RF-assisted ablation were required for these resections. Mean blood loss was 46 ml; no device other than RF ablation was required to obtain hemostasis. None of the patients needed a blood transfusion. Preoperative hemoglobin was 12.8 gm/dl and postoperative hemoglobin was 11.3 gm/dl. There were no perioperative deaths. Postoperative complications occurred in two patients: a liver abscess in one and heart failure in the other. The mean hospital stay was 9.4 days. This new approach, integrated with other techniques, reduces blood loss and coagulates the margins of resection during liver surgery. This new technique has two limitations: (1) it cannot be applied near main portal pedicles, and (2) it requires a long operative time. The best indication for this technique is when segmentectomy is required in patients with cirrhosis. Its role in major hepatic resections has yet to be determined. Further progress in the development of thermal ablation techniques and experience gained during the learning curve should help reduce the operative time, thereby improving the safety and efficacy of this procedure.

Paroxysmal positional vertigo: short- and long-term clinical and methodological analyses of 794 patients

Between 1995 and 2001, eight Italian clinical centres used the same diagnostic and therapeutic protocol in order to assess the clinical progress of paroxysmal positional vertigo and the benefits of an appropriate follow-up in prevention of relapse. The study population comprises 794 patients affected by paroxysmal positional vertigo. The study protocol comprised diagnostic staging including a complete otoneurological test, an anamnestic questionnaire aimed at identifying any possible risk factor, a blood test in basal conditions and monitoring of blood pressure. If necessary, more specific instrumental tests have been carried out. Appropriate rehabilitative manoeuvres were performed from 1 to 3 times within the same session. The patient was checked 3-5 days later: in the presence of a positive result, the treatment was repeated; if negative, patients were seen at clinical follow-up 7, 30, 180 and 365 days after recovery. Wherever possible, patients have been contacted 2 years after the first treatment and asked to answer a questionnaire and to attend for a clinical check-up. The incidence of paroxysmal positional vertigo appeared to be higher in females and in patients aged 50-70 years, being low in patients under 30. In 88.8% of cases posterior semicircular canals showed a significant involvement; in 6.8% of cases, only involvement of lateral semicircular canals; monolateral (2.7%) and bilateral (1.7%) multicanalar forms were rare. Paroxysmal positional vertigo forms involving posterior semicircular canals have been treated with Semont (simplified by Toupet), Epley, Parnes Price-Jones manoeuvres; those, involving lateral semicircular canals with Vannucchi-Vicini forced position and "barbecue" or Gufoni manoeuvre. Whilst all these manoeuvres were equally effective, longer recovery times have been observed in paroxysmal positional vertigo forms involving lateral semicircular canals when the Vannucchi-Vicini forced position was ineffective. Any relapses have been evaluated at least 15 days after a negative clinical pattern. Possible involvement of other semicircular canals (recurrence) some time after the first onset has been considered separately. Follow-up at 6 months showed recurrence in 12.4% of cases, while being chronic in 1.5% of cases. Only 9.3% of cases showed recurrence at 6 months, no statistically significant difference being observed between vertical (8.9%) and lateral canal (9.6%), forms. Relapses occurred in 3.1% of cases, in one third of which at least two risk factors were detected.

Red blood cell-mediated delivery of recombinant HIV-1 Tat protein in mice induces anti-Tat neutralizing antibodies and CTL

The immunotherapeutic potential of biologically active HIV-1 Tat protein coupled to autologous red blood cells (RBCs) was evaluated in a mouse model. HIV-1 Tat expressed in Escherichia coli and purified to homogeneity was found to be active in viral trans activation and efficiently internalised by monocyte-derived dendritic cells (MDDCs). The product of HIV-Tat biotinylation and coupling to RBCs by means of a biotin-avidin-biotin bridge, (RBC-Tat), showed no trans activation activity and was still efficiently internalized by MDDCs as compared to uncoupled Tat.Balb/c mice were then immunized with 10 microg of soluble Tat in complete Freund's adjuvant or with 40 ng of Tat coupled on RBCs surface and boosted at week 3, 6 and 25 with 5 microg soluble Tat in incomplete Freund's adjuvant or with 20 ng of RBC-coupled Tat, respectively. Anti-Tat antibody response was similar in both groups; however, 2/6 animals immunized with soluble Tat and 6/6 animals immunized with RBC-Tat developed anti-Tat neutralizing antibodies. In addition, at week 28 cytolytic anti-Tat CTLs were detected in all animals although they were slightly higher in mice immunized with RBC-Tat. These results indicate that RBC-mediated delivery of HIV-1 Tat, in amounts 250 times lower than soluble Tat, is safe and induces specific CTL responses and neutralizing antibodies.

Upper respiratory tract infections and pediatric anesthesia

Anesthesia for the child with an upper respiratory infection (URI) presents a challenge for the pediatric anesthesiologist. Differences in study design have made interpretation and comparison very difficult. The general lack of evidence-based research has led to disparities in the manner in which children which URI have been traditionally managed. Many studies have described associations between URIs and adverse events and we must decide whether to proceed or postpone the procedure and how long to postpone it. More recent research, however, suggests that children with uncomplicated infections can undergo elective procedures without significant increase in adverse anesthetic outcomes. This presentation summarizes the evolving literature about cancellation of surgery for the child with an upper respiratory infection, perioperative outcomes and anesthetic management.