SUICIDE ATTEMPT DUE TO METOCLOPRAMIDE-INDUCED AKATHISIA

Akathisia as a side-effect of metoclopramide has received increasing attention in consultation-liaison psychiatry in recent years. A case of metoclopramide-induced akathisia resulting in a suicide attempt is reported in order to highlight the suffering of such patients and the factors that lead to misdiagnosis.     

The neurosensory musculocutaneous tensor fasciae latae flap: long term results.

In 1971 we started covering pressure sores and unstable scars with transposition-rotation-muscle and musculocutaneous flaps. In 1980 we published the first results with 6 neurosensory musculocutaneous tensor fasciae latae flaps. Until April 1989, 31 tensor fasciae latae flaps (TFL) were used, and we review a consecutive series of 19 neurosensory TFL-flaps. Questions such as whether to delay the procedure; early and late complications; evolution of the sensation; and indications are outlined under the aspects of long term follow up studies. The conclusion is that if the neurological pattern permits a neurosensory flap, such flaps should be done because no local recurrence occurred. In extended neurosensory TFL-flaps sensation of the filling status of the rectum is improved, and sitting control and perception of the 'body scheme' are also improved.     

Experimental axonopathy induced by immunization with campylobacter jejuni lipopolysaccharide from a patient with guillain‐barré syndrome

Campylobacter jejuni (C. jejunj) infection is the most common antecedent in the axonal variant of Guillain‐Barré syndrome (GBS). Antibodies against nerve gangliosides found in GBS patients recognize cross‐reactive epitopes in the lipopolysaccharide (LPS) of C. jejuni. This led to the molecular mimicry hypothesis of GBS. We immunized eleven rabbits with a LPS extracted from HS:19 C. jejuni strain isolated from a patient with GBS and complete Freund's adjuvant (CFA)(group I). In a second experiment we immunized seven rabbits with LPS, CFA and keyhole limpet hemocyanin (KLH)(group II). All group I rabbits developed high titers of anti‐LPS, anti‐GM1, anti‐GD1b antibodies and lower titers of anti‐GD1a. One rabbit, 50 days after initial inoculation, showed tremor and weakness. All rabbits of group II developed high titres of antiganglioside antibodies and six animals showed weakness 59–113 days after initial inoculation. Two rabbits died. Pathology showed mild to moderate, tendentially grouped, axonal degeneration in sciatic nerves of four out of five animals. Control rabbits of group I (immunized with CFA only) did not develop antibodies, controls of group II (immunized with CFA + KLH) developed low titers of IgG anti‐GM1. None developed neurological signs or showed axonal degeneration. C. jejuni LPS is a potent B‐cell stimulator capable to induce a strong antiganglioside response in rabbits. However, to induce the neuropathy is crucial to employ KLH, a glycoprotein known to stimulate both humoral and cellular responses. This animal model reproduces the pathogenetic process hypothesized in axonal GBS with antiganglioside antibodies post C. jejuni infection.     

Randomised comparison of CHOEP versus alternating hCHOP/IVEP for high-grade non-Hodgkin's lymphomas: Treatment results and prognostic factor analysis in a multi-centre trial

Background: With CHOP, the standard protocol of recent decades,about 30% of long-term survival has been reported. A numberof studies using more aggressive multidrug regimens or alternatingchemotherapies have recently suggested higher CR rates and increasedsurvival. In 1989 we reported similar results with a combined-modalitytreatment administering 6 cycles of CHOP supplemented with etoposideand an involved field irradiation for patients in PR or CR. Patients and methods: To confirm the efficacy of this approach,we initiated a prospective randomised trial comparing 4 cyclesof CHOP-VP 16 (CHOEP) with 4 cycles of two alternating regimens,‘hCHOP and IVEP’. One hundred seventy-five patientswith high-grade non-Hodgkin's lymphomas stages II-IV were stratifiedfor age, stage and LDH and randomised to receive either fourcycles of cyclophosphamide, doxorubicin, vincristine, etoposide,prednisolone (CHOEP) in arm A or four cycles of chemotherapywith a dose-intensified CHOP (hCHOP) alternating with ifosfamide,etoposide, vindesine, prednisolone (IVEP) in arm B. After fourcycles of chemotherapy an involved field irradiation with atotal dose of 35 Gy was given to all patients demonstrated tobe in complete or partial remission. Results: Of the 185 randomised patients, 175 were eligible and171 evaluable for response and survival. One hundred forty-sixof the 171 patients (85%) achieved complete remission (CR) with87% and 84% CRs in arms A and B, respectively. With a medianfollow-up of 36 months the estimated overall survival at 2 yearsis 66% and 73% for arms A and B. The percentage of all patientsin first CR is estimated to be 59% and 55% at 2 years for armsA and B, respectively. None of the differences in CR rate, survival,or relapse-free survival are statistically significant. Multivariateanalysis of subgroups incorporating the factors of sex, age,performance status, stage, B symptoms, bulky disease, LDH andhistology revealed that only stage and LDH were factors whichindependently affected outcome. The estimated 2-year survivalrate of patients with stages II, III and IV is predicted tobe 84%, 62% and 52%, respectively. Patients with LDH >250U/I have an estimated survival of 52% at 2 years versus 84%for patients with LDH     

Role of serotonin in opiate-induced prolactin secretion and antinociception in the developing rat

Our laboratory has demonstrated previously that the ability of opiates to stimulate prolactin (PRL) release during ontogeny precedes the appearance of a PRL response to serotonergic drugs. The present study tests the hypothesis that opiates stimulate PRL secretion through a serotonergic mechanism in adult rats, but a nonserotonergic mechanism in neonatal rats. Morphine stimulated PRL secretion in adult and neonatal (10-day-old) rats and this increase was blocked with the opiate antagonist naloxone. Ten-day-old or adult rats were pretreated with the serotonin antagonist, cyproheptadine (CYPRO), or the neurotoxin, 5,7-dihydroxytryptamine (5,7-DHT). Both CYPRO and 5,7-DHT attenuated the PRL response to morphine in adult but not neonatal rats. 5,7-DHT decreased serotonin and 5-hydroxyindoleacetic acid substantially in the hypothalamus. When rats were pretreated with 5,7-DHT several weeks before morphine challenge, serotonin depletion was more pronounced, but the PRL response to morphine was not decreased. In addition, the PRL response to 5-hydroxytryptophan was greatly potentiated, suggesting that functional supersensitivity developed in the 5,7-DHT-treated animals. The ability of CYPRO and 5,7-DHT to block the serotonergic component of a different morphine-induced behavior in the neonate was tested using the tail immersion test for analgesia. Morphine produced profound antinociception in the rat pup which was attenuated markedly by 5,7-DHT and CYPRO. These studies demonstrate that opiates mediate their stimulatory effects on PRL release, at least in part, through a serotonergic mechanism in adult rats.(ABSTRACT TRUNCATED AT 250 WORDS)     

Acute renal failure in the outpatient setting

With the ever-increasing pressures for outpatient diagnostics and therapeutics, one must be increasingly alert to the occurrence and consequences of acute renal failure. The significance of minor increases in the serum creatinine level must be recognized, so that modifications of drug therapy can be made and correction of possibly life-threatening electrolyte imbalances can be undertaken. The multiple drug-related renal syndromes must be considered when initiating therapy with any medication. Prophy, laxis for acute renal failure with saline solution, mannitol, and/or furosemide should be considered in patients at increased risk.     

Moderate acute rejection detected during annual catheterization in pediatric heart transplant recipients.

BACKGROUND: Acute rejection commonly occurs within the first year after heart transplantation, and then decreases in frequency with time. Recently, the long-term utility of endomyocardial biopsy during routine annual catheterization has been questioned. The purpose of this study was to retrospectively review the prevalence of biopsy-proven rejection during routine annual catheterization in our patient population, determine whether biopsies late after transplant are useful, and identify factors that correlate with late unsuspected rejection. METHODS: Biopsy results from the annual catheterization were evaluated from 1986 to August 2000. The prevalence of moderate rejection was evaluated and compared with the patient's immunosuppressive regimen; the prevalence of late rejection; and how late rejection correlated with recipient age, number of first-year rejections and presence of sub-therapeutic cyclosporine. RESULTS: A total of 1108 biopsies were performed in 269 children with a mean follow-up of 5 +/- 3 years (median 5 years, range 1 to 11 years). Three-drug immunosuppressive therapy, including steroids, was used in 93 patients. There was a persistent 8% to 10% prevalence of moderate rejection at up to 10 years post-transplantation. Moderate rejection was more likely in patients: (1). on 3-drug immunosuppressive therapy; (2). with a recipient age >1 year; and (3). with a relatively lower cyclosporine level. CONCLUSIONS: These data suggest that continued surveillance of pediatric transplant patients for acute rejection is indicated for long-term follow-up.     

Secondary surfactant deficiencies in extremely low birth weight premature infants.]

Primary deficiency of surfactant is responsible for the respiratory distress syndrome and concerns premature neonates born before 33 weeks of gestation. However, newborns may develop respiratory disorders related to a secondary deficiency or dysfunction of surfactant. We report the course of three extremely low birth weight premature infants who experienced clinical respiratory decompensation at two weeks and showed a marked improvement after exogenous natural surfactant administration.