Treatment of clozapine-associated weight gain: a systematic review

PURPOSE

Clozapine is an antipsychotic drug with superior efficacy in treatment-resistant schizophrenia. Clozapine is associated with a low likelihood of extrapyramidal symptoms and other neurological side-effects but a high propensity to induce weight gain and general metabolic dysregulation. Various pharmacological and behavioral treatment approaches for reducing clozapine-associated weight gain exist in the literature; however, there are currently no clear clinical guidelines as to which method is preferred. The aim of the current review is to systematically summarize studies that have studied both pharmacological and non-pharmacological interventions to attenuate or reverse clozapine-associated weight gain.

METHODS

A systematic review of EMBASE and MEDLINE databases of all articles published prior to January 2014 was conducted. Seventeen studies were identified as meeting inclusion criteria and included in the review.

RESULTS

Aripiprazole, fluvoxamine, metformin, and topiramate appear to be beneficial; however, available data are limited to between one and three randomized controlled trials per intervention. Orlistat shows beneficial effects, but in males only. Behavioral and nutritional interventions also show modest effects on decreasing clozapine-associated weight gain, although only a small number of such studies exist.

CONCLUSIONS

While a number of pharmacological interventions can produce modest weight loss, each may be associated with negative side effects, which should be considered before beginning treatment. Given the pressing need to improve cardiometabolic health in most clozapine-treated patients, substantially more research is needed to develop sound clinical practice guidelines for the treatment of clozapine-associated weight gain.

Peripheral adrenoceptors: the impetus behind glucose dysregulation and insulin resistance

It is now accepted that several pharmacological drug treatments trigger clinical manifestations of glucose dysregulation, such as hyperglycaemia, glucose intolerance and insulin resistance, in part through poorly understood mechanisms. Persistent sympathoadrenal activation is linked to glucose dysregulation and insulin resistance, both of which significantly increase the risk of emergent endocrinological disorders, including metabolic syndrome and type 2 diabetes mellitus. Through the use of targeted mutagenesis and pharmacological methods, preclinical and clinical research has confirmed physiological glucoregulatory roles for several peripheral α- and β-adrenoceptor subtypes. Adrenoceptor isoforms in the pancreas (α(2A) and β(2) ), skeletal muscle (α(1A) and β(2) ), liver (α(1A & B) and β(2) ) and adipose tissue (α(1A) and β(1 & 3) ) are convincing aetiological targets that account for both immediate and long-lasting alterations in blood glucose homeostasis. Because significant overlap exists between the therapeutic applications of numerous classes of drugs and their associated adverse side-effects, a better understanding of peripheral adrenoceptor-mediated glucose metabolism is thus warranted. Therefore, at the same time as providing a brief review of glucose homeostasis in the periphery, the present review addresses both functional and pathophysiological roles of the mammalian α(1) , α(2) , and β-adrenoceptor isoforms in whole-body glucose turnover. We highlight evidence relating to the clinical use of common adrenergic drugs and their impacts on glucose metabolism.

Anterior internal capsule volumes increase in patients with schizophrenia switched from typical antipsychotics to olanzapine

Abnormalities in connectivity are thought to contribute to the symptoms of schizophrenia. Accumulating evidence suggests that antipsychotic medication affects both subcortical and cortical grey and white matter volumes. The goal of this study was to investigate the effects of antipsychotic medication on two white matter tracts: a subcortical-cortical tract, the anterior and posterior limbs of the internal capsule; and a cortical-cortical tract, the corpus callosum. Magnetic resonance imaging was conducted on 10 chronic schizophrenia patients treated with typical antipsychotics and 20 healthy controls at baseline. Patients were switched to olanzapine and both groups were rescanned after 1 year. At baseline, the volume of the anterior limb of the internal capsule was 24% smaller in typical-treated patients than controls (p = 0.009). Patients treated with greater amounts of chlorpromazine-equivalent daily dosage had smaller anterior internal capsule volumes at baseline (r = -0.65, p = 0.04). At follow-up, after being switched to olanzapine, there were no significant differences between patients and controls. Patients with schizophrenia had a significant 25% increase in anterior internal capsule volume from baseline to follow-up compared with controls (p = 0.04). These effects were most prominent in the anterior limb of the internal capsule, which consists of fronto-thalamic pathways, and were not statistically significant in the posterior limb of the internal capsule or corpus callosum. Olanzapine may be effective in normalizing fronto-thalamic structural connectivity in schizophrenia.

Intermittent treatment with olanzapine causes sensitization of the metabolic side-effects in rats

The second generation antipsychotic drugs are effective treatments for psychotic disorders. Many of these compounds, including the drug olanzapine, have been associated with metabolic side-effects, including weight gain, impaired glucose tolerance and insulin resistance, which increase the risk of developing cardiometabolic disorders. Rodent models of olanzapine-induced metabolic side-effects have been used to study the physiology of these effects, but only at a single time point after drug treatment. The purpose of the present study was to examine longitudinal changes with chronic antipsychotic drug treatment. Adult female rats were treated with either olanzapine (15 mg/kg) or vehicle for five consecutive days each week, followed by a 48 h washout period. Animals were then challenged with either olanzapine (15 mg/kg) or vehicle, and fasting glucose and insulin values were recorded, as well as glucose clearance in the glucose tolerance test. Treatment with olanzapine was continued for 10 weeks, with weekly tests of metabolic indices. Rats treated acutely with olanzapine showed both glucose dysregulation and insulin resistance; for the group treated during the week with olanzapine, these effects did not change by the end of ten weeks of treatment. However, in the group of animals challenged only once per week with olanzapine, the metabolic side-effects markedly intensified with the passage of time, whereby glucose intolerance and insulin resistance increased significantly compared to both baseline values and all other treatment groups. This previously unreported sensitization phenomenon represents a novel finding that may have clinical implications for patients receiving intermittent antipsychotic drug dosing or with variable adherence to treatment.

Region-specific transcriptional changes following the three antidepressant treatments electro convulsive therapy, sleep deprivation and fluoxetine

The significant proportion of depressed patients that are resistant to monoaminergic drug therapy and the slow onset of therapeutic effects of the selective serotonin reuptake inhibitors (SSRIs)/serotonin/noradrenaline reuptake inhibitors (SNRIs) are two major reasons for the sustained search for new antidepressants. In an attempt to identify common underlying mechanisms for fast- and slow-acting antidepressant modalities, we have examined the transcriptional changes in seven different brain regions of the rat brain induced by three clinically effective antidepressant treatments: electro convulsive therapy (ECT), sleep deprivation (SD), and fluoxetine (FLX), the most commonly used slow-onset antidepressant. Each of these antidepressant treatments was applied with the same regimen known to have clinical efficacy: 2 days of ECT (four sessions per day), 24 h of SD, and 14 days of daily treatment of FLX, respectively. Transcriptional changes were evaluated on RNA extracted from seven different brain regions using the Affymetrix rat genome microarray 230 2.0. The gene chip data were validated using in situ hybridization or autoradiography for selected genes. The major findings of the study are: 1. The transcriptional changes induced by SD, ECT and SSRI display a regionally specific distribution distinct to each treatment. 2. The fast-onset, short-lived antidepressant treatments ECT and SD evoked transcriptional changes primarily in the catecholaminergic system, whereas the slow-onset antidepressant FLX treatment evoked transcriptional changes in the serotonergic system. 3. ECT and SD affect in a similar manner the same brain regions, primarily the locus coeruleus, whereas the effects of FLX were primarily in the dorsal raphe and hypothalamus, suggesting that both different regions and pathways account for fast onset but short lasting effects as compared to slow-onset but long-lasting effects. However, the similarity between effects of ECT and SD is somewhat confounded by the fact that the two treatments appear to regulate a number of transcripts in an opposite manner. 4. Multiple transcripts (e.g. brain-derived neurotrophic factor (BDNF), serum/glucocorticoid-regulated kinase (Sgk1)), whose level was reported to be affected by antidepressants or behavioral manipulations, were also found to be regulated by the treatments used in the present study. Several novel findings of transcriptional regulation upon one, two or all three treatments were made, for the latter we highlight homer, erg2, HSP27, the proto oncogene ret, sulfotransferase family 1A (Sult1a1), glycerol 3-phosphate dehydrogenase (GPD3), the orphan receptor G protein-coupled receptor 88 (GPR88) and a large number of expressed sequence tags (ESTs). 5. Transcripts encoding proteins involved in synaptic plasticity in the hippocampus were strongly affected by ECT and SD, but not by FLX. The novel transcripts, concomitantly regulated by several antidepressant treatments, may represent novel targets for fast onset, long-duration antidepressants.

Interleukin-18 null mice show diminished microglial activation and reduced dopaminergic neuron loss following acute 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine treatment

Recent reports have revealed an involvement of microglial cells in dopaminergic neurodegeneration. In the present study, we tested the hypothesis that interleukin-18 (IL-18) plays a role in the microglial activation. The present study investigated microglial activation and dopaminergic neurodegeneration in substantia nigra pars compacta (SNpc) following 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) treatment in wild type (WT) and IL-18 knockout (KO) mice. The number of dopaminergic neuron loss in WT mice was significantly decreased 7 days after MPTP treatment compared with IL-18 KO mice. In WT mice microglial activation occurred in the SN at 1 day after MPTP treatment, progressively increased within the SNpc until 7 days post MPTP, and subsided by 14 days. In contrast, in IL-18 KO mice microglial activation occurred in the SN at 1 day post-MPTP, and decreased by 7 days, earlier than in WT mice. The lesser microglial activation and dopaminergic neurodegeneration in the SNpc following MPTP treatment in WT indicates the possibility that IL-18 may participate in microglial activation and dopaminergic neurodegeneration.

Altered immunoreactivity of complexin protein in prefrontal cortex in severe mental illness

Recent imaging and postmortem studies suggest that impaired connectivity is involved in the pathophysiology of schizophrenia and major affective disorders. We investigated the presynaptic proteins complexin (Cx) I and Cx II in postmortem prefrontal cortex in schizophrenia (n = 13; six suicide, seven nonsuicide), major depression (n= 11, all suicide) and controls (n = 11) with an enzyme-linked immunoadsorbent assay (ELISA). Overall analysis indicated a significant difference between groups (F = 3.93, P = 0.007). Cx I (enriched in inhibitory terminals) was decreased 33% in schizophrenia (26% in schizophrenia/nonsuicide, 42% in schizophrenia/suicide) and 27% in major depression. Cx II (enriched in excitatory terminals) was not significantly different. Analysis of the ratio of Cx II/Cx I was carried out as an indication of the balance of excitatory to inhibitory terminals. A significant difference between groups (ANOVA, F = 6.42, P = 0.005) was observed. The mean value of Cx II/Cx I was significantly increased by 34% in schizophrenia (26% in schizophrenia/nonsuicide and 43% in schizophrenia/suicide) and by 32% in depression compared with control (Student-Newman-Keuls test, P = 0.05). Immunoreactivities of the two complexins were highly correlated in all groups. However, compared with controls and depression, samples from cases with schizophrenia appeared to have relatively less Cx I for similar amounts of Cx II. Immunocytochemical studies of rat frontal cortex after 3 weeks treatment with chlorpromazine, trifluoperazine or haloperidol revealed no differences in complexins, synaptophysin, SNAP-25, syntaxin or VAMP in comparison with animals treated with vehicle. Alterations of complexins may contribute to the molecular substrate for abnormalities of neural connectivity in severe mental disorders.

Effects of amisulpride on consummatory negative contrast

Two groups of rats, 'shifted' (32-4% sucrose) and 'unshifted' (4-4% sucrose), were given access to sucrose solutions for 5 min/day for 10 days. On day 11, shifted animals had access to a devalued incentive (4% sucrose) and subgroups of each group received doses of amisulpride (10 or 60 mg/kg, i.p.) or its vehicle before a 10-min access period to sucrose solutions. Lick frequency was measured both pre- and post-shift. A high dose of amisulpride reduced successive negative contrast (SNC) after a brief period of exposure to the devalued stimulus, whereas a low dose had no effect. The acute effects of high doses of amisulpride seem to act on contrast effects in a similar way to anxiolytic compounds such as the benzodiazepine, chlordiazepoxide.

Paradoxical effects of chronic corticosterone on forced swim behaviours in aged male and female rats

The effects of chronically administered corticosterone on forced swim test and open field test behaviours were explored in aged male and female rats. Though corticosterone has typically been associated with depressive behaviours, recent data have suggested a putative antidepressive effect of corticosterone. The current study used the forced swim test as a model of antidepressant efficacy in order to explore this. Aged male and female rats received either corticosterone (20 mg/kg) or the vehicle for 10 days before testing in the forced swim test, then for an additional 3 days before testing in the open field test. On day 11, each animal was individually tested on the duration of swimming, immobile, and struggling behaviours, and on day 14, for the display of rearing and line crossing behaviours. Results revealed that corticosterone significantly increased swimming and decreased immobility behaviour in females, but failed to do so in males. Additionally, there was a main effect of corticosterone on struggling behaviour such that it decreased it in males. There were no effects of corticosterone or sex on open field test behaviours, suggesting that the present findings are not accounted for by a general effect of corticosterone on motor behaviour. Overall, the data suggest that chronically administered corticosterone possesses effects that are sex-specific, and that it may exert mildly antidepressive effects in females, but the opposite effects in males. These data are consistent with emerging evidence that corticosterone may play a paradoxical antidepressive effect.

Estradiol alleviates depressive-like symptoms in a novel animal model of post-partum depression

The effect of hormone withdrawal following hormone-simulated "pregnancy" on "depressive-like behavior" in the Forced Swim Test (FST) was investigated in female Long-Evans rats. Females were randomly assigned to "pregnant", "pregnant"+estradiol benzoate (EB), and control groups. Both the "pregnant" and "pregnant"+EB groups received daily injections of the hormones estradiol and progesterone to simulate the 23-day gestational period in the rat. However, the "pregnant"+EB group continued to receive daily estradiol injections after "pregnancy". All groups were tested 48 h after the last injection of the pregnancy period in the FST and subsequently in the Open Field Test (OFT). Results revealed that the "pregnant" rats exhibited significantly increased immobility and decreased struggling and swimming behaviors as compared to the "pregnant"+EB and control groups. These findings could not be explained by an overall depression in general locomotor activity among "pregnant" rats, as the "pregnant" rats made more area crossings in the OFT. Thus "pregnant" rats exhibited behaviors consistent with "depressive-like" symptoms "post-partum" (after their hormone regime was discontinued). Continual treatment with high levels of estradiol in the "pregnant"+EB group, however, reversed the exhibition of these behaviors. These results imply that withdrawal from chronic high levels of pregnancy-associated hormones (estradiol and progesterone) can produce depressed symptomology in rodents, which can be prevented by prolonging exposure to high levels of estradiol through the post-partum period. These findings are the first demonstration of "depressive-like" symptoms in a rodent model of post-partum pregnancy and the ability of high levels of estradiol to attenuate these "depressive-like" symptoms.

Chronic corticosterone enhances the rewarding effect of hypothalamic self-stimulation in rats

Excessive levels of glucocorticoids have been implicated in the etiology of affective disorders in humans, and in a range of behavioral deficits in animals. In the present study, we used an established regimen of corticosterone administration (40 mg/kg, for 21 days) to determine its effects upon responding for rewarding brain stimulation in rats. After chronic treatment, subjects exhibited an unexpected but significantly increased sensitivity to the rewarding effects of brain stimulation. These results suggest that chronic, high levels of corticosterone are unlikely to cause anhedonia in rodents.

Sex differences in forced-swim and open-field test behaviours after chronic administration of melatonin

The effects of melatonin administered chronically on forced-swim test and open-field test behaviours were examined in male and female rats. The forced-swim test has been shown to be sensitive to all major classes of antidepressants and evidence indicates that melatonin possesses putative antidepressive properties. Male and female Long-Evans rats received either a regimen of chronic administration of melatonin or the control condition for 14 days via the drinking water. On day 15, each animal was individually introduced into a swim chamber, and was scored for 15 min on the duration of swimming, struggling, and immobility. After 24 h, each animal was again tested in the forced-swim test for 10 min. On day 18, all animals were tested in the open-field test apparatus for 5 min. Results revealed that females consistently showed higher activity levels than males in the forced-swim and open-field tests. Melatonin significantly increased struggling in males on day 15, but failed to do so in females. Also, whereas melatonin-treated females showed higher levels of behavioural immobility during their first exposure to the forced-swim test, this effect was prevented upon a second exposure. In both males and females, melatonin decreased swimming in the forced-swim test while increasing open-field ambulatory behaviour. Therefore, it is unlikely that melatonin's mechanism of action is a general inhibitory effect on motor activity. Taken together, the results suggest that the effects of melatonin treatment on forced-swim test behaviours are sex- and test-dependent.

Effects of withdrawal from an escalating dose schedule of d-amphetamine on sexual behavior in the male rat

The present study sought to determine the effect of withdrawal from an escalating dose schedule of d-amphetamine on sexual behavior in male rats. Tests were conducted every 5 days until stable levels of sexual behavior were obtained. With repeated testing, male rats displayed an increase in their exploration of the testing chambers prior to the introduction of an estrous female. Half of the male rats were then subjected to a 4-day escalating dose schedule of d-amphetamine administration (1-12 mg/kg), while half received vehicle. Twelve hours after the final drug injection, subjects were tested for sexual behavior. Withdrawal from the drug was associated with decrements in several motivational components of sexual behavior, including decreased anticipatory locomotor and increased postejaculatory intervals, while consummatory measures remained largely unaffected. This pattern of sexual deficits resembles those seen in human depressive disorders, and therefore, provides additional support for the use of psychostimulant withdrawal as a rodent model of depression.

Withdrawal following repeated exposure to d-amphetamine decreases responding for a sucrose solution as measured by a progressive ratio schedule of reinforcement

Numerous studies have shown that withdrawal from sustained high doses of psychostimulant drugs such as cocaine or d-amphetamine produces depressive-like symptoms in both rats and humans. The majority of experiments with rodents have assessed the effects of amphetamine withdrawal on reinforcing electrical self-stimulation in different brain regions, but relatively few have examined effects on responding for natural reinforcers. In the present study, two groups of mildly food and water deprived male rats were trained to respond on a lever for a 4% sucrose solution under a progressive ratio schedule of reinforcement. One group was subsequently administered a 4-day regimen of injections of increasing doses of d-amphetamine based on a schedule shown previously to reduce self-stimulation behaviour. Break points were significantly reduced for up to 4 days after the termination of drug administration, suggesting a decreased motivation to obtain the natural reward. A further experiment demonstrated that the identical drug regimen produced no effect upon consumption of the 4% sucrose solution when it was freely available. These results demonstrate that the progressive ratio procedure may be a useful technique for evaluating changes in motivation for natural reinforcing stimuli following withdrawal from psychostimulant drugs.

Chronic mild stress has no effect on responding by rats for sucrose under a progressive ratio schedule

Exposure of rats to chronic unpredictable mild stress (CMS) has been shown to produce a syndrome in which a wide range of consummatory behaviors are attenuated, resembling a state of anhedonia, which may be reversed by treatment with antidepressant drugs. The aim of the present study was to determine whether CMS would also affect a rat's motivation to respond for a sucrose solution, as assessed by its performance under a progressive ratio (PR) schedule of reinforcement. Control studies demonstrated that break points in nonstressed rats were sensitive to both the concentration of sucrose solution used, as well as the period of food and water deprivation used prior to testing. Exposure of rats to CMS had no effect upon break points when responding under a progressive ratio schedule for either a 1% or 7% sucrose solution, although subjects did display the typical reduction in consumption of a freely consumed 1% sucrose solution. These results are not readily understood within the theoretical framework of the CMS model of anhedonia and imply instead that both the neural and psychological correlates of motivation may be less susceptible to modulation by the effects of CMS than the free consumption of sweet solutions.

Stimulation of the ventral subiculum of the hippocampus evokes glutamate receptor-mediated changes in dopamine efflux in the rat nucleus accumbens

The effects of electrical stimulation of the ventral subiculum/CA1 region of the hippocampus on changes in dopamine oxidation current (corresponding to dopamine efflux) in the nucleus accumbens were examined using in vivo chronoamperometry with stearate-graphite paste electrodes in urethane-anaesthetized rats. Burst-patterned monophasic pulses (10-100 Hz/burst delivered at 0.8-4 Hz) evoked a three-component change in dopamine efflux in the nucleus accumbens with an initial transient increase in the dopamine signal above baseline, followed by an immediate decrease below baseline, and thereafter by a prolonged increase in the dopamine signal above baseline. 6-Hydroxydopamine lesions of the mesoaccumbens dopamine pathway or transection of the fimbria-fornix blocked all of the evoked changes in the dopamine signal. Both the first and third components of enhanced dopamine efflux were blocked by microinfusion into the nucleus accumbens of the ionotropic glutamate receptor antagonists (+/-)-2-amino-5-phosphonopentanoic acid, 6,7-dinitroquinoxaline-2,3-dione and kynurenate. Burst stimulation-evoked decreases in the dopamine signal were abolished following microinfusions into the nucleus accumbens of the metabotropic glutamate receptor antagonist (+)-alpha-methyl-4-carboxyphenylglycine. These results suggest that ventral subiculum/CA1 glutamatergic inputs to the nucleus accumbens may presynaptically modulate dopamine efflux by synaptic activation of both ionotropic and metabotropic glutamate receptors in the nucleus accumbens. These glutamate-dopamine interactions may constitute part of the mechanisms by which hippocampal signals are integrated through selective modulation of dopamine release in the nucleus accumbens in both physiological and pathological conditions.

Fibreoptic bronchoscopy under general anaesthesia using the laryngeal mask airway

The laryngeal mask airway was used to facilitate fibreoptic bronchoscopy under general anaesthesia in 140 adult patients. Following placement, the position of the mask was observed through the fibreoptic bronchoscope. Three different positions were identified. In 120 patients (86%) the concave surface of the mask faced the larynx directly with or without some unfolding of the epiglottis. In 17 patients (12%) the laryngeal mask appeared to be at an angle facing one pyriform fossa and in two patients the tip of the mask lay anterior to the arytenoids. No problems with ventilation or maintenance of an acceptable airway were encountered. In one patient repositioning of the laryngeal mask was necessary to allow the passage of the bronchoscope. One patient developed laryngospasm and required tracheal intubation.

General anaesthesia for trans-bronchial lung biopsy

A technique of general anaesthesia is described which has been used for trans-bronchial lung biopsy in 100 patients. Sixty-seven were day cases. An early pneumothorax was detected in four patients, but only one needed tube drainage.

The prevention of pain on injection. A study of the effect of intravenous lignocaine before methohexitone

The effect of pre-injection of lignocaine 10 mg or physiological saline was assessed in a double blind trial on 100 unpremedicated day cases having a methohexitone induction. The incidence of pain was reduced from 64% to 22% using lignocaine.

Thiopentone and fazadinium crash induction. A comparison with thiopentone and pancuronium

A method of crash induction using fazadinium and thiopentone was studied in 100 patients not genuinely at risk from regurgitation. Speed and ease of intubation compared well with a previous study using pancuronium. Cardiovascular stability was not as good as with pancuronium and tachycardia was the major concern. Fourteen patients were assessed as 'difficult' to reverse and three recurarised.

Premedication with lorazepam for bronchoscopy under general anaesthesia

Lorazepam 3 or 4 mg i.m. was given to 100 patients as premedication before bronchoscopy under thiopentone-suxamethonium anaesthesia. Forty-nine of the patients assessed as anxious received oral lorazepam as preoperative night sedation also. Lorazepam was an effective night sedative. Forty-two of the 49 patients slept well and were calm and co-operative in the morning. Following the i.m. injection of lorazepam, 64% of patients had complete lack of recall for 4--10 h following premedication. Only 5% recalled correctly a simple objective test of memory initiated in the anaesthetic room. The frequency of recall was higher in those who consumed alcohol regularly and in females. There was one case of awareness during bronchoscopy in a patient who received only a small dose of lorazepam (2.8 mg per 70 kg). Side-effects were minimal and patient acceptance was impressive. These results show an advance on previous studies using pethidine and diazepam. Further improvement is needed, particularly in adjusting the dose of lorazepam to body weight and to factors such as age, sex and alcohol intake.

Thiopentone and pancuronium crash induction. A comparison with thiopentone and suxamethonium

A method of 'crash induction' using pancuronium and thiopentone was studied in 100 patients at risk from vomiting or regurgitation. The technique was inferior to thiopentone/suxamethonium in terms of time to intubation, activity of vocal cords and responses to stimuli during induction. Six cases gave difficulty with intubation due to poor relaxation. Only two patients had a fall in systolic blood pressure of more than 20% following induction. No regurgitation occurred. The technique may be suitable for skilled anaesthetists in cases when suxamethonium is relatively contraindicated, when large doses of pancuronium can be used or when hypotension is likely to follow induction.

The effect of diazepam and lorazepam on awareness during anaesthesia for Caesarian section

One hundred-and-eighty-three patients having general anaesthesia for Caesarian section were given lorazepam or diazepam intravenously immediately following delivery. The incidence of unpleasant recall was comparable with the reports of other workers. There was no evidence of a specific retrograde amnesic effect by either drug. Neither agent appeared to affect cardiovascular stability, uterine contraction, the reversal of muscle relaxant or the time to recovery of protective reflexes. The patients tended to be drowsier after lorazepam but as safe as after diazepam so far as circulation, respiration and protective reflexes were concerned.

A case of drowning

A case of near drowning is described. Despite full consciousness on early admission, and apparently good immediate recovery following intensive therapy for delayed pulmonary effects, the patient died of overwhelming necrotising pneumonia on the tenth day after the accident.

Thiopentone and suxamethonium crash induction. An assessment of the potential hazards

A technique of 'crash induction' using thiopentone and suxamethonium with cricoid pressure was studied in 100 unselected patients at risk from vomiting or regurgitation. No episode of regurgitation occurred. There was difficulty with intubation due to poor relaxation in 7 patients and, in 61 cases, it was believed that there was some evidence of a potential hazard from raised intra-abdominal pressure other than due to fasciculation. Systolic blood pressure rose more than 20% in 19 patients, and fell more than 20% in 9 patients.