ECT resistance and early relapse: two cases of subsequent response to venlafaxine

Many depressed patients who fail to respond to numerous trials of antidepressant medications are ultimately referred for electroconvulsive therapy (ECT). However, a complete response does not occur in all depressed patients referred for ECT. The erroneous portrayal of ECT as a 'last ditch' treatment of depression leads to predictable despair if ECT fails or if early relapse occurs after a brief response. Therapeutic nihilism is not warranted in these cases. There is evidence in the literature that patients who fail to respond to adequate trials of antidepressant medications prior to ECT failure or early relapse subsequently respond to psychopharmacological treatment with high doses of venlafaxine. The following two case reports provide examples of depressed patients who subsequently responded to high doses of venlafaxine after demonstrating resistance to ECT, or experiencing rapid relapse after successful ECT.     

The outcome of 369 ECT consultations

OBJECTIVE: The components of a pre-ECT consultation have been well-described, but the outcome has not been described. We describe the outcome of 369 consecutive ECT consultations. METHODS: We performed a retrospective review of ECT consultations performed at Wake Forest University School of Medicine between January 23, 1992, and October 22. 1998. Each consultation was coded as either recommending against ECT, unenthusiastic about ECT, or recommending ECT. RESULTS: Thirteen percent of the patients at their first consultation needed clarification of their capacity to consent to ECT. Additional testing was recommended in 34%, and additional medical consultation was recommended for 11% of the patients. The ECT consultation recommended against ECT for 4% of patients, was unenthusiastic for an additional 15% of patients, and was enthusiastic for 81%. Likelihood of receiving ECT was strongly influenced by the consulting physician's level of enthusiasm for ECT. Enthusiasm for ECT, in turn, was highly related to diagnosis. CONCLUSIONS: The recommendations from an ECT consultation appeared influential in the likelihood of receipt of ECT. The consultation's enthusiasm for ECT, in turn, was related to the patient's diagnosis. Furthermore, the consultation revealed the need for additional testing, medical consultation, or clarification of capacity to consent in a substantial number of patients.     

Achilles tendon (TA) size and power Doppler ultrasound (PD) changes compared to MRI: a preliminary observational study

AIM: To assess whether abnormal Achilles tendon (TA) magnetic resonance imaging (MRI) and spectral ultrasound (US) features have associated development of microvascular power Doppler (PD) flow. MATERIALS AND METHODS: In a prospective, controlled and blinded study six patients with TA symptoms were compared to five with other ankle abnormalities. Two radiologists independently measured the mean maximal anteroposterior diameter on MRI and conventional US (categorized as normal <6 mm, mild 6.1-10 mm, moderate 1.1-1.5 cm and severely enlarged > 1.6 cm), assessed morphology and studied the vessels using power Doppler. They formed a consensus over discrepancies. Sonography of the contralateral side within 24 h was used as a control. RESULTS: Twenty-one tendons in six women and five men, aged 45-77 years (mean 57.6 years), were examined, 12 tendons were of normal US morphology and size (< 6 mm), and did not exhibit PD's flow (interobserver agreement K > 0.74). Of the 12 tendons studied by MRI five were normal, seven tendons were enlarged, five of which had a proportionate increase in PD flow at the margin on the deep surface and four also had vessels in the centre of the tendon. All five of these tendons had high signal on T2-weighting (T2W). Of the two mildly enlarged tendons of intermediate signal on T1 and T2W, one showed PD flow and the other did not. CONCLUSIONS: In patients with TA disease power Doppler ultrasound shows proliferation of vessels in enlarged, abnormal tendons demonstrated on MRI and standard ultrasound, in the absence of definite tears.     

Accuracy of blood loss determination by health care professionals

Patients undergoing surgery will likely experience some degree of blood loss. There is much literature examining effects of blood loss, but little was found that examined accuracy of estimation of blood loss. The research question for this study was: How accurate are surgical health care professionals in their estimations of blood loss? This study was a pre-experimental between-subject design that used a convenience sample of 85 volunteers who worked in the surgical and postsurgical units of a rural southern 450-bed hospital. The participants viewed 1 of 3 randomly chosen samples of laparotomy pads with variable amounts of blood and saline. Only the researchers knew the exact amount contained on the pads. The variables that were examined and were compared included the professional group, years of experience in surgery or the postanesthesia care unit (PACU), and their estimation of blood loss. Their estimation of blood loss was compared with the actual amount of blood to determine whether one group was more accurate than another statistically and whether increasing years of experience improved accuracy. The statistical tests used were simple and multiple regressions.     

Placenta percreta: report of a case

Placenta accreta, increta, or percreta are rare but potentially lethal obstetric emergencies. Removal of abnormal growth of the placenta into the uterine wall is difficult or impossible and results in massive blood loss. Hysterectomy may be necessary to save the mother's life. The common predisposing factors in development of placenta percreta are repeat cesarean and placenta previa. The diagnosis of placenta percreta may remain undiagnosed until delivery. The case presented describes a scenario involving placenta percreta with bladder involvement in which the diagnosis was known in advance. The article describes the preoperative preparation, intraoperative events, and postoperative status of this particular case.     

Eosinophilic heart disease presenting with features suggesting hypertrophic obstructive cardiomyopathy

We report a 25-year-old female with characteristic features of eosinophilic heart disease on clinical presentation, echocardiography, cardiac catheterization, and LV endomyocardial biopsy. Concomitant physical examination and echocardiographic findings suggesting hypertrophic obstructive cardiomyopathy resolved during treatment with anticoagulation and prednisone therapy.     

Enhancement of the murine primary antibody response by phenylephrine in vitro.

Phenylephrine was found to enhance the primary (immunoglobulin M) antibody response of murine splenocytes to sheep erythrocytes when added to splenocyte cultures at the time of in vitro immunization. The enhancement was seen at all times during the developing antibody response. One day after the peak response the enhancement was 78% above the control response, and was completely blocked by equimolar concentrations of the alpha adrenoceptor antagonist phentolamine. The alpha-1 adrenoceptor antagonist prazosin dose dependently antagonized the enhancement associated with phenylephrine one day after the peak response. These results suggest that phenylephrine prolongs the in vitro IgM antibody response by way of alpha-1 adrenoceptor activation. The adrenoceptors responsible for this pharmacologic response could not be demonstrated using direct radioligand binding techniques.