Antidepressant effects of high and low frequency repetitive transcranial magnetic stimulation to the dorsolateral prefrontal cortex: a double-blind, randomized, placebo-controlled trial.

Repetitive transcranial magnetic stimulation (rTMS) has antidepressant effects in patients with major depressive disorder. The mechanisms of action and optimal stimulation parameters remain unclear. To test the hypothesis that rTMS exerts antidepressant effects either by enhancing left dorsolateral prefrontal cortex (DLPFC) excitability or by decreasing right DLPFC excitability, the authors studied 45 patients with unipolar recurrent major depressive disorder in a double-blind, randomized, parallel group, sham-controlled trial. Patients were randomized to receive 1 Hz or 10 Hz rTMS to the left DLPFC, 1 Hz to the right DLPFC or sham TMS. Left 10 Hz and right 1 Hz rTMS showed similar significant antidepressant effects. Other parameters led to no significant antidepressant effects.

Internal fixation of femoral neck fractures with posterior comminution: a biomechanical study.

OBJECTIVES: This study was performed to determine whether four cancellous lag screws provide significantly improved rigidity and fixation strength compared with three screws for fixation of displaced femoral neck fractures with posterior comminution. DESIGN: Biomechanical cadaver study. INTERVENTION: Eight pairs of mildly osteopenic femurs were selected, and each pair was fixed with three or four cancellous lag screws (randomly assigned) after the creation of a simulated femoral neck fracture with posterior comminution. A separate comparison with an unmatched group of six similar femurs with a simulated femoral neck fracture without posterior comminution and instrumented with three screws was performed to investigate the effect of posterior comminution. MAIN OUTCOME MEASUREMENT: The specimens were non-destructively tested to determine fixation rigidity in axial and anterior loading. Cyclic axial loading was then performed for 10,000 cycles; the femurs were retested for rigidity and finally were axially loaded until failure. RESULTS: The femurs with a posterior defect stabilized with three screws had significantly less resistance to axial and anterior displacement and sustained significantly lower axial loads to failure than those stabilized with four screws. The specimens instrumented with three screws without a posterior defect exhibited greater resistance to displacement in anterior loading and sustained greater axial loads to failure than those with a posterior defect stabilized with three screws. CONCLUSION: This study suggests that there are benefits to using four screws for fixation of femoral neck fractures with posterior comminution.

Intramedullary versus extramedullary fixation of subtrochanteric fractures. A biomechanical study.

We compared two different subtrochanteric fracture fixation techniques, an intramedullary hip screw system (IMHS) and an extramedullary, dual sliding screw-plate system (MSP), to determine relative fixation stability. 6 matched pairs of osteosynthesized osteopenic cadaver femurs were axially loaded to 1000 N with concurrent, simulated abductor forces of 0%, 50%, or 86% of the applied head force. The initial loading sequence was made with uniaxial dynamization--the lag screw of the MSP locked and distal locking of the IMHS nail. Femoral head displacement and medial femoral strain were measured for intact femur controls, after fixation of a 2-part reverse oblique subtrochanteric fracture and finally a 3-part reverse oblique subtrochanteric fracture with a lateral wedge defect. The samples were then loaded at 750 N for 10(4) cycles with both devices uniaxially locked, followed by 10(4) cycles with both devices fully biaxially dynamized (unlocked). For the 2-part subtrochanteric fracture pattern, both devices exhibited similar inferior displacements of the femoral head (average 2.0 mm) and medial femoral strain (approximately 70% of intact). Increasing abductor forces decreased medial compressive strain but did not significantly affect head displacement. For the 3-part fracture model, the MSP demonstrated significantly less inferior displacement of the head (1.6 mm vs. 2.1 mm) and both devices demonstrated significantly decreased medial strain. After cycling, head displacement increased approximately 50% in both devices and medial strain increased slightly. After unlocking and cycling, the MSP group showed significant lateral displacement of the proximal fragment. The IMHS and MSP devices provide similar stability for fixation of 2-part and 3-part reverse oblique subtrochanteric fractures. In a biaxially dynamized, 3-part reverse oblique fracture, displacement of the proximal fragment can occur with the MSP.

Use of the Medoff sliding plate for subtrochanteric hip fractures.

OBJECTIVE: To evaluate the effects of dynamization of a sliding hip screw plate on the fixation stability for several types of subtrochanteric fractures. Clinical results of treating reverse oblique fractures occasionally show medialization of the femoral shaft. DESIGN: Two types of plate dynamization were compared using the same test protocol in identically prepared groups of uniform, artificial femurs. METHODS: Sawbones composite femurs (Pacific Research Labs, Vashon, WA) having five orientations of simulated subtrochanteric fractures were used with the Medoff plate (Medpac, Inc., Valencia, CA) either fully dynamized or with the sliding lag screw locked. These specimens were physiologically loaded and cycled and displacements of the proximal femur determined. RESULTS: Significantly more shaft medialization occurred with reverse oblique fracture patterns when the Medoff plate was fully dynamized. CONCLUSION: Clinical treatment of reverse oblique fractures with the Medoff plate should be performed using the lag screw locked and only the plate dynamized.

A research-based reconsideration of the psychoanalytic theory of dreaming.

We present a brief review of sleep research which, when combined with psychoanalytic experience, has led to the hypothesis that REM sleep and dreaming serve the function of adaptation by the process of integration of information. We then report the results of a study of dreams, based on this hypothesis. We studied dreams and their relation to waking mental activity and found a correlation between problems in manifest dreams and those in pre- and postsleep waking life. Dreams can be understood on the basis of problems that appear in them. We also found evidence for a relation between the solution of problems in dreams and the fate of those problems the next day. We discuss these findings in relation to some of the controversies about dreaming, and then present suggestions for future research.

Electroconvulsive therapy. Current concepts.

Recent developments in the practice and theory of ECT are reviewed. Indications, efficacy, and risk/benefit considerations are discussed with emphasis on the clinical utility and cost-effectiveness of increased and earlier usage of ECT in hospitalized patients. Treatment procedures are presented in some detail with listings of medical considerations, management of complications, and other applications to general hospital practice. Research on the mechanism of action, potential future developments, and some training issues are briefly discussed.

Creatine kinase elevation after neuroleptic treatment.

Two cases of asymptomatic elevation of creatine kinase levels after oral neuroleptic treatment are described. One patient was successfully challenged with a different neuroleptic. The authors discuss possible reasons for creatine kinase elevation.

Neuroleptic malignant syndrome: a review of the literature.

The neuroleptic malignant syndrome (NMS) involves fever, extrapyramidal rigidity, and disturbances of autonomic function and consciousness. It occurs more often with high potency and depot forms, frequently 3 to 9 days after initiation and sometimes years later, and is not related to dose or previous exposure. About 40% of cases had evidence of an affective disorder. NMS apparently results from deficient compensatory mechanisms following blockade of dopaminergic regulation of muscle tone and autonomic function. Possible indicators of vulnerability and various treatments are discussed. Neuroleptic challenge resulted in recurrence of symptoms in about one third of cases. Symptoms sometimes subsided despite continued treatment. Early diagnosis and effective treatment have reduced the risk of such challenge.

Hyperthyroidism in a patient with agitated depression: resolution after electroconvulsive therapy.

A patient with hyperthyroidism is described whose clinical presentation was that of agitated depression. Her psychologic abnormality and thyroid hyperfunction responded to electroconvulsive therapy.

The capacity of stroke patients to report dreams.

We studied the capacity of stroke patients to report dreams following awakening from REM sleep. Four left-hemisphere aphasia and two right-hemisphere visuospatial deficit patients reported dreams. The expression of ideas in dreams appeared normal despite the patients' waking difficulties. Given their similar rules of grammar, both dream and phonetic language modalities could emanate from common sites.

Alprazolam-induced mania: two clinical cases.

Two patients treated with alprazolam had histories suggestive of a bipolar disorder and developed lithium-responsive manic episodes. The authors caution that treatment with alprazolam may be complicated by the induction of mania.