Serotonin syndrome complicating migraine pharmacotherapy

Serotonin syndrome, a condition with numerous clinical neurological manifestations, is the result of central serotonergic hyperstimulation. Features of the syndrome include mental status and behavioral changes (agitation, excitement, hypomania, obtuniation), motor system involvement (myoclonus, hemiballismus, tremor, hyperreflexia, motor weakness, dysarthria, ataxia) and autonomic symptoms (fever, chills, diarrhea). Serotonin syndrome has been reported exclusively in patients on medications for psychiatric illness and Parkinsonism, despite the fact that the putative action of many antimigraine agents also involves the serotonin system. We herein report six patients with migraine who developed symptoms suggestive of the serotonin syndrome. Five were taking one or more serotomimetic agents for migraine prophylaxis (sertraline, paroxetine, lithium, imipramine, amitriptyline). In each case the symptoms and signs developed in close temporal proximity with use of a migraine abortive agent known to interact with serotonin receptors. In three instances the agent was subcutaneous sumatriptan and, in three, intravenous dihydroergotamine. In each instance the symptoms were transiers and there was full recovery. With the ever increasing use of migraine medications active at serotonin receptor sites, cases of serotonin syndrome will likely occur more frequently. It is important that physicians creating migraine are aware of the serotonin syndrome and are able to recognize its varying presentations.     

Aneurysms of the right ventricular outflow tract after tetralogy of Fallot repair: role of radiology

Eight patients with aneurysms of the right ventricular outflow tract patch following tetralogy of Fallot repair were found to have residual distal obstructions. The site of such an obstruction must be carefully documented preoperatively because failure to relieve significant distal obstruction may result in recurrent aneurysm formation. Chest radiography; echocardiography, including Doppler analysis; and cardiac catheterization, including angiocardiography, each have a role in the detection and evaluation of this complication.     

The International Headache Society (IHS) Headache Classification as applied to a headache clinic population

Four hundred patients attending a headache clinic were classified using the IHS criteria. The majority required more than two, often three or four, diagnoses. Even though migraine was the most common diagnosis, only 1/4 of those with a migraine diagnosis had it as the only diagnosis. Seventy-five percent of migraine patients had coexistent chronic tension-type headache (CTTH), drug-induced headache or both. Ninety-six percent of patients diagnosed as having migraine with aura also suffered from migraine without aura. More than 1/3 of patients (37.7%) attending the clinic suffered from chronic daily headache (CDH) (chronic cluster headache excluded), which is not included as a separate entity in the IHS classification. Pure CTTH formed only a small minority of CDH, whereas 86.6% of CDH had migraine as one of the diagnoses. Drug-induced headache was a prominent second or third diagnosis. The advantages and disadvantages of multiple verses single diagnosis in CDH and the need to recognize the natural history of headache disorders in the classification are discussed.     

Indications and Operative Outcomes of Gastric Bypass Reversal

Background

Roux-en-Y gastric bypass (RYGB) is one of the best-known and most commonly performed bariatric procedures. However, this procedure carries infrequent but serious long-term complications, which may require revisional procedures. This study reports the indications and outcomes of gastric bypass reversal that have not been described well in the literature.

Methods

A multicenter retrospective study of 50 patients who underwent reversal of RYGB conducted between 2006 and 2015 was reviewed to describe the usual indications and outcomes of gastric bypass reversal surgeries.

Results

Of 50 patients, 7 (14 %) were males and 43 (86 %) were females. The mean age of the patient population was 40.4?±?11.6 years (range 19–66). Reasons for reversal included anastomotic ulcers (n?=?27), anastomotic complications (n?=?9), malnutrition (n?=?2), and functional disorder (n?=?12). The mean BMI before the reversal was 29?±?9.4 kg/m² (range 16–60). The mean time between the primary procedure and reversal was 60?±?65.5 months (range 2–300). Fourteen of the reversals were done via laparotomy. Mean hospital stay was 8.4?±?7.3 days (range 3–34 days). There was no peri-operative death 30 days after reversal. Following gastric bypass reversal, 92.6 % (n?=?25) of the patient population had resolution from ulcers, 77.8 % (n?=?7) of the patient population had resolution from anatomic complications, 100 % (n?=?2) of the patient population had resolution from malnutrition, and 66.7 % (n?=?8) of the patient population had resolution from functional disorders.

Conclusions

Gastric bypass reversal is a reasonable and safe treatment for complications arising from the GBP surgery. A laparoscopic approach is feasible in select patients.