Additional evidence of the abuse potential of quetiapine

Quetiapine is an atypical antipsychotic agent approved by the FDA for the treatment of schizophrenia, acute mania, and bipolar depression. Recently, reports of medication abuse, particularly intranasal and i.v. abuse, have been described. Three cases of oral misuse of quetiapine are presented and clinical implications are discussed. Clinicians should exercise caution when prescribing quetiapine to patients at risk for substance abuse.     

Catastrophizing is associated with clinical examination findings, activity interference, and health care use among patients with temporomandibular disorders

AIMS: To examine whether catastrophizing is associated with clinical examination findings, pain-related activity interference, and health care use among patients with pain related to temporomandibular disorders (TMD). METHODS: Patients with TMD (n = 338; 87% female; mean age, 37 years) completed measures of pain, pain-related activity interference, health care use, and depression, and received a Research Diagnostic Criteria/ Temporomandibular Disorders (RDC/TMD) clinical examination from an oral medicine specialist. RESULTS: Catastrophizing was not significantly associated with the more objective clinical examination measures of maximum assisted jaw opening and jaw-joint sounds, but it was associated with the more subjective examination measures (unassisted opening without pain, extraoral muscle site palpation pain severity, joint site palpation pain severity) and with increased TMD-related activity interference and number of health care visits (P values for all < .01). Even after controlling for demographic variables, pain duration, and depression severity, catastrophizing remained significantly associated with extraoral muscle and joint site palpation pain severity and with activity interference and number of health care visits. CONCLUSION: TMD patients who catastrophize have higher scores on clinical examination measures reflecting more widely dispersed and severe pain upon palpation of TMD-related facial muscle and joint sites, as well as greater TMD-related activity interference and health care use. Clinicians should consider screening patients with moderate or greater TMD pain and activity interference for catastrophizing. Cognitive-behavioral interventions may help reduce pain, disability, and health care use of patients who catastrophize.     

Gender-related differences in morbidity and mortality during combined valve and coronary surgery

BACKGROUND: Gender-related differences in morbidity and mortality are well described for coronary artery bypass grafting but are not well understood for combined valve and bypass surgery. METHODS: We reviewed retrospectively the morbidity and mortality of 1570 consecutive patients who underwent combined valve and bypass procedures at the Toronto General Hospital between January 1990 and October 2000. RESULTS: There were 1073 men (68%) and 497 women (32%). The mean ages (+/- 1 SD) of women and men were 69 +/- 9 and 68 +/- 9 years, respectively (P =.02). Of the 1570 total patients, 973 patients (62%) underwent aortic valve and coronary bypass surgery, 481 patients (31%) had mitral valve and coronary bypass operations, and 116 (7%) patients had double or triple valve and coronary bypass operations. Preoperative hypertension (P =.002), diabetes (P =.001), and atrial fibrillation (P =.001) were seen more frequently in women. Body surface area was significantly lower in women (P =.0001). At presentation, more women were in congestive heart failure (69% vs 58%, P =.001) and in New York Heart Association functional class III or IV (25% vs 19%, P =.001). Although there was no difference in the number of women with three or more diseased vessels (32% vs 38%), only 35% of women received three or more grafts compared with 44% of men (P =.001). The use of left internal thoracic grafts, although uncommon in the whole study population (36%), was less common in women than in men (26% vs 41%, P =.001). Multivariable logistic analyses for morbidity and mortality showed female gender to be an independent risk factor. Mitral valve replacement, age, left ventricular dysfunction, New York Heart Association classes III and IV, and association of tricuspid valve disease, diabetes, peripheral vascular disease, and preoperative renal failure were found to be independent risk factors for mortality. CONCLUSION: Female gender is an independent risk factor for combined morbidity and mortality during and after combined valve and coronary bypass surgery. As with isolated coronary artery bypass grafting, women undergoing combined procedures have more premorbid conditions, are more often in heart failure, had an equal incidence of triple vessel disease but received fewer grafts than men, and, therefore, were more frequently incompletely revascularized.     

Persistent left ventricular false aneurysm after transapical insertion of an aortic valve

Transcatheter aortic valve implantation (TAVI), via either a femoral or apical approach, has been developed as an alternative to conventional aortic valve replacement for patients whose operative risks are considered too high for conventional surgery. Complications with these relatively new procedures are being reported with increasing frequency. We report a case of transapical TAVI, in which the patient developed a false aneurysm at the apex of the left ventricle as a complication of the procedure.     

Decreasing mortality for coronary artery bypass surgery in octogenarians

BACKGROUND:

Octogenarians are the fastest growing population in Canada and have also been referred for coronary artery bypass grafting (CABG) with increasing frequency during the past decade.

OBJECTIVE:

To examine the changing trends in preoperative risk profiles, postoperative outcomes and hospital resource use in the octogenarian population.

METHODS:

A retrospective review was conducted to identify all patients 80 years of age or older who underwent isolated CABG at the Toronto General Hospital (Toronto, Ontario) between 1990 and June 2005. To examine the effect of time on preoperative risk, patients were divided into three groups based on year of operation: 1990 to 1994, n=92; 1995 to 1999, n=202; and 2000 to June 2005, n=314.

RESULTS:

The preoperative risk profile of octogenarians undergoing CABG has changed over the years. The percentage of patients with diabetes, dyslipidemia, hypertension and left main disease increased over time (P<0.05). However, the requirement for urgent/emergent operations decreased. In-hospital mortality declined from 7.1% (1990 to 1999) to 3.2% (2000 to June 2005, P=0.02). The prevalence of low cardiac output syndrome, intra-aortic balloon pump insertion and stroke decreased over time. Preoperative myocardial infarction (OR 4, P=0.0004), left main disease (OR 3.7, P=0.0013) and year of operation (1990 to 1994 [OR 3.3, P=0.03]; 1995 to 1999 [OR 2.9, P=0.02]) independently predicted in-hospital mortality. Hospital resource use in terms of hours on ventilator, length of stay in the intensive care unit and postoperative length of stay decreased over time (P<0.0001).

CONCLUSION:

Despite a changing risk profile, hospital outcomes of octogenarians were improved over time with a reduction in hospital resource use. The results suggest that CABG can and should be performed in this expanding population.     

Interobserver Reproducibility and Biological Variability of the Surgicutt II Bleeding Time

The bleeding time is a readily and easily performed clinical test with immediate results, but there is a degree of subjectivity in its performance and interpretation. We performed a study on 27 volunteers designed to determine the normal range, interobserver reproducibility, and biological variability of the test. Bleeding times in these normal subjects ranged from as low as 129 seconds to as high as 803 seconds. The interobserver variability was 106 seconds (2 standard deviations of the mean of the differences of paired results of repeated measurements), and the coefficient of variation was 18%. For bleeding times taken on the same subjects 6 weeks apart, when the same nurse performed the test at both visits, the difference was 150 seconds (2 standard deviations of the mean of the differences of paired samples) and the coefficient of variation was 27%, and they were essentially the same if a different nurse performed the tests at each visit. There is a wide range in the bleeding times among subjects. However, within individuals there is little biological variability, and most of the difference over time is due to interobserver variability. This suggests that changes in bleeding time are clinically useful in predicting platelet responsiveness in individual patients.     

Epidural meperidine analgesia after cardiac surgery

Epidural meperidine (1 mg X kg-1) was administered for relief of sternal pain to ten patients, at a mean of 24.8 hours after infusion of high dose fentanyl for cardiac surgery. Lung function, cough, pain score, somnolence, respiratory rate, PaCO2, pulse and blood pressure were studied before and for six hours after analgesic administration. Following epidural meperidine, four of ten patients were pain-free, and three had only minimal pain. Duration of analgesia was 8.8 +/- 4.9 hours. Cough score was significantly improved for five hours. Postoperatively vital capacity was approximately 40 per cent, and FEV1 was approximately 55 per cent of the preoperative value. There was no significant change in FEV1 or vital capacity, following analgesia with epidural meperidine. The somnolence score increased in seven patients. In the first two hours after epidural meperidine, three patients exhibited a fall in their respiratory rate, one had a PaCO2 greater than 45, and two of these patients had marked hypotension. These side effects are easily treated without mechanical or pharmacological support, and do not preclude the use of epidural meperidine after a high dose fentanyl anaesthetic.