Plasma fluphenazine levels and clinical response in newly admitted schizophrenic patients

Seventy-two newly readmitted, drug-free men with the diagnosis of schizophrenia by DSM-III were assigned randomly to receive fluphenazine hydrochloride at 5 mg, 10 mg, or 20 mg daily for 4 weeks. Fluphenazine (FLU), fluphenazine sulfoxide, 7-hydroxyfluphenazine, and fluphenazine N-oxide were measured by highly specific and sensitive radioimmunoassays. Data were analyzed by logistic regression using the Clinical Global Impressions Disabling Side Effects and Global Improvement as the outcome measures. Disabling side effects were defined as "side effects that significantly interfered with patient's functioning" or "side effects that outweigh therapeutic effects" (National Institute of Mental Health 1985, p. 839). Higher plasma FLU levels (up to 4.23 ng/mL) were significantly (p = .015) associated with a higher rate of global improvement. However, close to 90 percent of these acute patients had disabling side effects at a plasma FLU level of 2.7 ng/mL. At least in the patient's view, these disabling side effects negated or compromised the improvement in psychosis. Fluphenazine N-oxide may be a toxic metabolite in that it was more powerfully associated with side effects than was the parent FLU.     

Vaginal vault suspension by posterior transobturator sling

OBJECTIVE: A study on the feasibility and safety of a new surgical procedure of vaginal vault suspension using a polypropylene mesh placed in the uterovaginal septum by a posterior transobturator approach. PATIENTS AND METHODS: Longitudinal study from March 2002 to January 2006 of patients treated by this new surgical procedure. Postoperative visits, including an interview and a physical examination were made at two, six and 12 months and annually thereafter. The minimal required follow-up time was 12 months up to January 2007. RESULTS: Seventy-eight patients were included. Three cases of intraoperative bleeding occurred. In these cases no transfusion was required and no complications were observed later on. The mean hospital stay was five days (range 3-9). The mean follow-up time was 20.36 months (range 12-48). Six recurrences were observed in the medial compartment (8%) and two anterior recurrences (2%). There was no recurrence in the posterior compartment. New-onset moderate dyspareunia was noted in 13% of the cases and a severe in two cases. No erosion occurred. DISCUSSION AND CONCLUSION: The analysis of our experience shows that vaginal vault suspension by posterior transobturator approach is a safe and simple procedure, and demonstrates its median efficacy. Further, this study should confirm these results over the long-term follow-up.     

Acute aortic insufficiency

Acute aortic insufficiency can now be diagnosed rapidly and accurately thanks to Doppler echocardiography. The etiologies include infectious endocarditis, aortic dissection, bioprosthesis degeneration and thoracic injury. The clinical diagnosis is substantiated by the particular etiological context, dyspnea and pulmonary edema being the main factors involved. Examination includes finding out whether there is a reduction in the first sound, S1 a generally brief apical diastolic murmur. Echocardiography detects the presence of aortic leakage, the acute character of which is confirmed by the findings of a premature closure of the mitral valve, the existence of telediastolic mitral leakage, a restriction in the transmitral flow, and finally, the absence of left ventricular dilatation. An emergency operation is recommended by most authors in the case of acute aortic leakage due to the major risk or mortality resulting from pulmonary edema, ventricular arrhythmias, electromechanical dissociation or cardiogenic shock.     

Results of a French multicentre retrospective experience with four hundred and eighteen failed unicondylar knee arthroplasties

Purpose

By means of a multicentre retrospective study based on the failure of 418 aseptic unicondylar knee arthroplasties (UKA) our aims were to present the different types of revision procedure used in failed UKAs, to establish a clear operative strategy for each type of revision and to better define the indications for each type of revision.

Methods

Aseptic loosening was the principal cause of failure (n = 184, 44 %) of which 99 cases were isolated tibial loosening (23.5 % of the whole series and 54 % of all loosening), 25 were isolated femoral loosening (six and 13.6 %) and 60 were both femoral and tibial loosening (14.3 and 32.6 %). The next most common causes of failure were progression of arthritis (n = 56, 13.4 %), polyethylene wear (n = 53, 12.7 %), implant positioning errors (n = 26), technical difficulties (n = six) and implant failure (n = 16, 3.8 % of cases). Data collection was performed online using OrthoWave™ software (Aria, Bruay Labuissiere, France), which allows collection of all details of the primary and revision surgery to be recorded.

Results

A total of 426 revisions were performed; 371 patients underwent revision to a total knee arthroplasty (TKA) (87 %), 33 patients (7.7 %) were revised to an ipsilateral UKA, 11 (2.6 %) patients underwent contralateral UKA (ten) or patellofemoral arthroplasty (one) and 11 patients (2.6 %) underwent revision without any change in implants.

Conclusions

Before considering a revision procedure it is important to establish a definite cause of failure in order to select the most appropriate revision strategy. Revision to a TKA is by far the most common strategy for revision of failed UKA but by no means the only available option. Partial revisions either to an alternative ipsilateral UKA or contralateral UKA are viable less invasive techniques, which in carefully selected patients and in experienced hands warrant consideration.     

Myasthenia gravis, pregnancy and delivery: a series of ten cases

OBJECTIVE: To study the reciprocal interferences between pregnancy and myasthenia gravis (MG) and to describe obstetric and anaesthetic management during labour and the post-partum period. STUDY DESIGN: Retrospective, single centre study. METHODS: The files of 10 patients with MG, who delivered between October 1994 and May 2002, were examined. RESULTS: No stillbirth occurred and all pregnancies were brought to term. All patients were maintained on their long-term anticholinesterase medications during pregnancy. Seven exacerbations were detected and controlled, five by increasing the anticholinesterase treatment, one by using plasmapheresis and one by using intravenous immunoglobulins. No patient required admission to the intensive care unit during pregnancy. All patients had a pre-anaesthetic visit at/near 33 weeks of gestation. Delivery was induced for six patients. Regional analgesia was performed early in labour (epidural, n = 7; combined spinal-epidural = 2) using low concentrations of local anaesthetic and no complication was detected. Three patients required a caesarean section for an obstetrical indication. Seven patients delivered vaginally using instrumental extraction (n = 5). During the post-partum period, four patients were monitored in the intensive care unit during 48 h and close neurological follow-up disclosed no exacerbation during the first 6 post-partum weeks. CONCLUSIONS: MG has no significant effect on the course of pregnancy and delivery, but MG exacerbation can occur, especially in the first trimester. Regional analgesia is medically indicated and must be performed early in labour, using low concentration of local anaesthetic to lessen the risk of motor block.