Magnetic resonance cholangiopancreatography at 3T in a single breath-hold: comparative effectiveness between three-dimensional (3D) gradient- and spin-echo and two-dimensional (2D) thick-slab fast spin-echo acquisitions

Background

To compare the depiction conspicuity of three-dimensional (3D) magnetic resonance cholangiopancreatography (MRCP) based on gradient- and spin-echo (GRASE) and two-dimensional (2D) thick-slab MRCP using fast spin-echo (FSE) in different segments of hepatic and pancreatic ducts at 3T.

Methods

Both 3D GRASE and 2D thick-slab FSE MRCP, with parameters adjusted under the constraints of specific absorption rate and scan time within single breath-hold, were performed for 95 subjects (M/F =49:46; age range, 25-75) at 3T. Conspicuity of eight ductal segments was graded by two experienced raters using a 4-point score. Situations where one technique is superior or inferior to the other were recorded.

Results

3D GRASE MRCP outperformed 2D thick-slab FSE MRCP in the common bile duct and common hepatic ducts (both with P<0.001), but compared inferiorly in the right hepatic ducts (P<0.001), right posterior hepatic ducts (P<0.005) and pancreatic duct distal (P<0.05). Performing both 3D and 2D MRCP would reduce the number of non-diagnostic readings in the left hepatic duct to 10 remaining (5.3%), compared with 31 (16.3%) or 21 (11.1%) out of 190 readings if using 3D GRASE or 2D thick-slab FSE alone, respectively.

Conclusions

Although 3D GRASE MRCP is preferential to visualize the common bile duct and common hepatic duct within one single breath-hold, the complementary role of 2D thick-slab FSE MRCP in smaller hepatic and pancreatic ducts makes it a useful adjunct if performed additionally.

A mass of flesh: schizophrenic Rorschach percepts

The present study reports the recent finding that schizophrenic patients produce Rorschach percepts implying a mass of flesh (flesh mass). Although typically directly referring to a mass of flesh or muscle, the flesh masses were seen more broadly, in modified forms such as animals or human beings with diminution of head, arms, or legs. From observations on 76 chronic schizophrenics, inclusion and exclusion criteria were developed to reliably detect both explicit and implicit flesh masses. The presence or absence of the flesh mass was further examined in the Rorschach data of 22 patients with acute schizophrenia, 30 with anxiety disorders, 16 with psychotic mood disorders, and 28 normal adults. Diagnoses were made according to DSM-IV. Flesh masses were seen in 75 of 76 cases of chronic schizophrenia, in all cases of acute schizophrenia, in two patients with anxiety disorders, and in one patient with a mood disorder. Normal adults did not perceive any flesh mass. Flesh masses proved to be characteristic of schizophrenia, whether chronic or acute.

Lack of pharmacokinetic interaction between buspirone and haloperidol in patients with schizophrenia

The pharmacokinetic interaction between buspirone and haloperidol was evaluated in schizophrenic patients in two different groups. In both groups, haloperidol doses (10-40 mg/day) remained constant for 6 weeks before the addition of buspirone 10 mg three times daily. Serial blood samples were obtained from the 11 patients in group I at baseline (before addition of buspirone) and after administration for 24 hours. The pharmacokinetic parameters of haloperidol were determined alone and with coadministration of buspirone. In group II, buspirone 10 mg three times daily was added to treatment with haloperidol in 27 patients. Blood samples were obtained before addition of buspirone and at weeks 2 and 6 of treatment with buspirone. Samples were obtained 10 to 12 hours after administration of the evening dose and before the morning dose. Haloperidol and its metabolite, reduced haloperidol (RH), were assayed by means of high-performance liquid chromatography with electrochemical detection. Significant changes in the pharmacokinetic parameters of haloperidol were not found in group I; a mean increase in the half-life (t1/2) of haloperidol from 21.5 to 28.1 hours was observed, but this finding was not statistically significant. Under steady-state conditions, plasma levels of haloperidol in the patients in group II did not change significantly from baseline to week 6. Plasma concentrations of RH remained unaltered in both groups. The results indicate that coadministration of buspirone does not markedly affect the pharmacokinetics or plasma concentrations of haloperidol.

Disposition of remoxipride in Chinese schizophrenic patients

The disposition of remoxipride was evaluated in 13 male chronic schizophrenic patients. A single 150 mg dose of remoxipride was administered and blood sampling performed over the following 48 hours. The mean (SD) oral clearance and half-life of remoxipride were 74.46 (25.9) ml/min and 5.46 (0.87) hours, respectively. The mean (SD) AUC for remoxipride was 25,320 (9,820) ng.h/ml. A wide interpatient variability was observed. Compared to Caucasian studies there were no significant differences in the disposition of remoxipride.

Plasma haloperidol and reduced haloperidol concentrations in a geriatric population

Haloperidol (HL) and reduced haloperidol (RH) plasma concentrations were measured in geriatric patients (n = 45) and schizophrenic patients (n = 8). In the elderly patients, HL doses were 1-4 mg/day while only 2 mg/day was used in the schizophrenics. At HL 2 mg/day dose in both age groups, mean plasma HL levels were approximately twice as high in the elderly patients compared to the schizophrenics (1.39 +/- 0.82 vs. 0.56 +/- 0.23 ng/ml, p < 0.02). RH plasma concentrations were almost 5 times greater in the elderly patients (0.54 +/- 0.35 vs. 0.09 +/- 0.05 ng/ml, p < 0.0001). These results suggest that HL plasma concentrations in the elderly are greater than in adult schizophrenic patients treated with similar HL doses.

Ketone reductase activity and reduced haloperidol/haloperidol ratios in haloperidol-treated schizophrenic patients

Twenty schizophrenic patients were treated with a fixed haloperidol (HL) dose of 20 mg/day for 4 weeks. The conversion of HL to its reduced metabolite (reduced haloperidol, RH) occurs via the ketone reductase enzyme. RH is also converted back to HL by the cytochrome P450 2D6 isozyme. Ketone reductase activity can be measured in red blood cells. Plasma HL and RH levels were assayed by high performance liquid chromatography. Blood samples were obtained at baseline and during weeks 2 and 4 of HL therapy. Seventeen of 20 patients had ketone reductase values < 3. A significant correlation between ketone reductase and RH/HL plasma ratios was observed at week 4 in these 17 patients. Patients with ketone reductase activity < 3 could represent a subgroup of patients that metabolize HL differently. The wide interpatient variability observed with HL and RH plasma levels in HL-treated patients could reflect differences in ketone reductase activity and the metabolic status of debrisoquin hydroxylase (cytochrome P450IID6) in psychiatric patients.

Plasma reduced haloperidol/haloperidol ratios in schizophrenic patients treated with high dosages of haloperidol

Plasma haloperidol (HL) and reduced haloperidol (RH) levels were measured in 60 schizophrenic patients treated with high to very high HL doses of 40-200 mg/day. Plasma samples were obtained at steady-state conditions and 10-12 h after the evening dose and prior to the morning dose. RH/HL ratios were shown to be dose-dependent. In the lowest dose group of 40-45 mg/day, 77% of the patients had RH/HL ratios < 1.0. At the higher dose of 60-80 mg/day, these results were reversed as 79% of the patients had RH/HL ratios > 1.0. All patients with HL doses greater than 100 mg/day had RH/HL ratios > 1.0. All patients safely tolerated the high haloperidol dosages and only five patients had extrapyramidal side effects that were unresponsive to trihexyphenidyl. Therapeutic improvement was not observed in each patient. Based upon the dose-dependent increase in the RH/HL ratios in schizophrenic patients, the possible mechanism of a 'therapeutic' window for HL is discussed.

Plasma homovanillic acid and treatment response in a large group of schizophrenic patients

Plasma levels of homovanillic acid (pHVA), a metabolite of dopamine, were measured in ninety-five Chinese schizophrenic patients free of neuroleptics for at least four weeks. These patients were treated with classical antipsychotics for six weeks. Pretreatment pHVA was positively correlated with the subsequent clinical response (r = 0.408, p < 0.0001). Good responders (BPRS improvement > or = 50%, n = 47) had higher pretreatment pHVA levels than poor responders (BPRS improvement < 50%, n = 48) (15.7 +/- 8.4 ng/ml versus 9.9 +/- 3.7 ng/ml, p < 0.0001). A higher than 15 ng/ml pretreatment pHVA level was associated with a more consistent clinical response to the subsequent treatment. Using a pHVA level of 12 ng/ml as a demarcation point, 72% of patients (34 of 47) who had pHVA > or = 12 responded whereas 65% (31 of 48) who had < 12 did not respond (chi-square = 13.02, p < 0.0001). These results suggest that higher pretreatment pHVA levels may predict a better clinical response to antipsychotics. Based upon the pHVA findings, two hypothetical subtypes of schizophrenia are proposed.

Prolonged haloperidol and reduced haloperidol plasma concentrations after decanoate withdrawal

Haloperidol and reduced haloperidol plasma concentrations were measured in twelve schizophrenic patients upon cessation of haloperidol decanoate (HLD) treatment. Each patient received HLD 100 mg every 4 weeks for five injections. After the fifth injection, HLD was discontinued. Haloperidol and reduced haloperidol plasma concentrations were obtained prior to cessation and at weeks 1, 3, 4, 5, 7, 9, 11, and 13 post-injection. Haloperidol and reduced haloperidol plasma concentrations were assayed by HPLC. Both haloperidol and reduced haloperidol plasma concentrations were detectable 13 weeks post HLD discontinuation. Maximal haloperidol plasma concentrations were observed at one week post cessation and gradually declined. The mean elimination half-life for haloperidol was 27.4 +/- 8.6 days (range 19.0-47.0 days). Reduced haloperidol plasma concentrations declined very slowly. Our results show that both haloperidol and reduced haloperidol plasma concentrations can remain for extended time periods after HLD is discontinued.

Reduced haloperidol/haloperidol ratios after oral haloperidol and decanoate administration in schizophrenics

1. Haloperidol and reduced haloperidol plasma concentrations were measured in thirteen stable schizophrenic patients that received both oral haloperidol and haloperidol decanoate. 2. Significant correlations between reduced haloperidol/haloperidol ratios from oral haloperidol and haloperidol decanoate occurred at week two and week 16, respectively. 3. The formation of RH was consistent during haloperidol decanoate treatment.

Comparison of haloperidol and reduced haloperidol plasma levels in four different ethnic populations

1. Plasma haloperidol and reduced haloperidol concentration were measured in four ethnic populations. 2. Plasma samples were obtained under steady-state conditions and obtained 10-12 hours post bedtime dose and prior to the morning dose. 3. Haloperidol and reduced haloperidol plasma levels were assayed by radioimmunoassay and liquid chromatography. 4. A wide interpatient variability between haloperidol dose and plasma concentration was observed for each ethnic group. 5. The Chinese group differed from the other ethnic populations. 6. A nonlinear relationship was observed between haloperidol and reduced haloperidol plasma levels in each ethnic group. Further, the relationship of haloperidol to reduced haloperidol plasma levels differed for each ethnic group. These results suggest that various ethnic groups could metabolize haloperidol and reduced haloperidol differently.

Coma following ECT and intravenous droperidol: case report

A 60-year-old man with psychotic depression became comatose following the administration of intravenous droperidol given for post-ECT delirious agitation. The differential diagnosis, which included neuroleptic malignant syndrome and the possibility that droperidol may have uniquely detrimental effects in the context of post-ECT delirium, are discussed. In light of recent publications advocating droperidol as the pharmacologic treatment of choice for severe agitation, this case illustrates a need for greater caution in its use for the treatment of post-ECT delirium.

A study of medication refusal by involuntary psychiatric patients

The authors evaluated 31 patients consecutively admitted to a locked acute treatment unit in California to determine the severity of their symptomatology, their attitudes toward treatment, and whether they would refuse medication if they had the opportunity (patients in California do not have the right to refuse). Fifteen patients indicated that they would refuse medication if given the opportunity. Although they did not differ in diagnosis from the other patients, they showed evidence of more severe psychosis and higher mood elevation and had less positive attitudes toward treatment. Two-week follow-up of 12 patients in the refuser group showed that they were less likely to refuse drugs and were clinically improved; however, six of the patients still preferred to refuse medication despite their clinical improvement. The authors discuss their findings in the context of the broader issue of when a mentally ill person should be forced to give up the power to make decisions about drug treatment.

A comparison of patients who refuse and consent to neuroleptic treatment

A recently enacted regulation in California requires that voluntary mental patients give signed informed consent for treatment with antipsychotic drugs. To evaluate the law's effects on schizophrenic patients, the authors compared 15 patients who refused to give consent with a matched group of 15 who gave consent. Refusers had significantly higher scores on the Brief Psychiatric Rating Scale for conceptual disorganization, emotional withdrawal, and unusual thought content. They were also more hostile, uncooperative, and mistrustful of the treatment team and more likely to believe they were not ill. The authors raise questions regarding the most appropriate consent process for schizophrenic patients.

Generic and trade-name antipsychotic drugs: clinical equivalence

The clinical inequivalence of generic versus trade-name drugs has been reported for nonpsychiatric drugs but rarely for psychotropic drugs. Recent expiration of patents on some psychotropic drugs has made the evaluation of the clinical equivalence of generic versus trade-name drugs a matter of interest from methodological, sociopolitical, and economic aspects. The authors discuss these points, with emphasis on methodology, in their report of a double-blind study of the efficacy of chlorpromazine and Thorazine in the treatment of 54 acute schizophrenic patients. An analysis designed to infer the maximum possible advantage of Thorazine over generic chlorpromazine indicated that differences between the two were clinically insignificant.

American psychopharmacology: second class status?

In the July 1964 issue of The Atlantic, William Sargant (6), made some controversial comments on American psychiatry. “Freudian converts”, he said, fear “allowing any other methods of psychiatric treatment to gain any real recognition and acceptance in … teaching centers” where physical and biochemical treatments are “dismissed” as “symptomatic” and “second-rate”. He argued, furthermore, that psychoanalysts' views are unrealistic because these practitioners are experienced merely with the “very mildest forms of mental illness”. “Only psychoanalysis holds out any real hope in treatment” is the credo which Dr. Sargant attributes to U.S. psychoanalysts. If these opinions were solely those of one author, they might be overlooked, but they are held by many European and American psychiatrists (1).