Primary psychosis with comorbid drug abuse and drug-induced psychosis: Diagnostic and clinical evolution at follow up.

The study reports a follow-up assessment of 48 patients with concomitant drug abuse at the first admission for psychosis. We focused on the diagnostic distinction between primary psychosis with concomitant drug abuse and drug induced psychosis, to observe whether the diagnoses are stable over time and whether the clinical course significantly differs. The study examined 25 primary psychotic disorder with comorbid drug abuse and 23 drug-induced psychotic disorder patients. Diagnostic and psychopathological assessments were made at baseline and at follow-up. Mean follow-up period was 4.96 years. Patients with comorbid Drug Abuse exhibited higher scores in the item Unusual Content of Thought at baseline than drug-induced psychotic disorder patients: 5.48 vs 4.39 while the two patients groups did not differ in any of the BPRS items evaluated at follow-up. The primary psychosis with comorbid drug abuse and the substance induced psychosis groups were similar regarding diagnostic stability, and a diagnosis of schizophrenia at follow-up occurred similarly. There was no evidence that Drug Induced psychotic patients' symptoms tend to improve more after cessation of drug abuse. An earlier age of onset was found in primary psychotic patients, particularly for patients diagnosed as affected by schizophrenia at follow up. These results might reflect the uncertainty of the distinction between Primary and Drug Induced Psychosis and the difficulties in applying the DSM IV-TR criteria for diagnosing comorbid drug use disorders and psychotic disorders.

Paliperidone for the treatment of schizophrenia and schizoaffective disorders - a drug safety evaluation.

INTRODUCTION: Paliperidone, the major active metabolite of risperidone, is a second-generation antipsychotic that has been developed as an extended-release (ER) oral formulation and a long-acting injectable paliperidone palmitate (PP) formulation. Paliperidone has demonstrated efficacy in the reduction of acute schizophrenia symptoms and clinical benefits were maintained also in the long-term treatments. Paliperidone ER and PP are generally well tolerated with a predictable adverse event profile. Areas covered: Data from studies evaluating safety and tolerability in the acute and maintenance treatment of schizophrenia with paliperidone are reviewed. The reported treatment-emergent adverse events of these formulations are discussed. Expert opinion: In the treatment of schizophrenia and schizoaffective disorders the safety profile has a central role because it can enhance patient compliance. In fact treatment-emergent adverse events are one of the main causes of discontinuation in these patients. In particular the main limitation in the administration of paliperidone could be represented by the onset of hyperprolactinemia (especially in women) and of mild parkinsonism. Paliperidone has a high impact on current long-term drug strategies, especially given the new 3 month long-acting injectable formulation of PP.

Traumatic anterior hip dislocation associated with anterior and inferior iliac spines avulsions and a capsular-labral lesion.

A 16-year-old man had a traumatic accident during motor-cross racing and sustained an anterior hip dislocation with fracture of anterior superior and anterior inferior iliac spines. The hip was emergently reduced and further imaging was obtained to evaluate the lesion and bony fragments. Computed tomography confirmed the presence of two large fragments and a small fragment from the antero-inferior acetabulum. The patient underwent open reduction and internal fixation of the iliac spines and the reparation of anterior hip capsule. No complications occur after 1 year of follow-up. We present the case and a review of the literature for this lesion.

Popliteal artery pseudoaneurysm after a revision of total knee arthroplasty: endovascular treatment with a stent graft.

Injury to the popliteal artery during total knee arthroplasty is a very rare but dangerous complication. Several mechanisms are capable of generating a direct trauma to the vessel, like posterior retractor and oscillating saw. We report a case of popliteal artery pseudoaneurysm in a 52-year-old woman that occurred during revision of total knee arthroplasty, requiring emergency repair by means of percutaneous endovascular covered stenting.

Blunt splenic rupture--experience in a preserving non-operatively orientated care team in a tropical hospital.

OBJECTIVES: With a view to the prevention of immediate and later complications of splenectomy, especially the risk of overwhelming post-splenectomy sepsis syndrome (OPSS), conservative treatments have been proposed when the haemodynamic condition of the patient permits this. In this study, we present our experience in a preserving non-operatively orientated care team in a tropical hospital. PATIENTS AND METHODS: Twenty patients admitted to Hoima Hospital, Hoima, Uganda with splenic injuries from blunt abdominal trauma between July and December 1995 were included in the study. For every patient, serial monitoring of clinical and haematological data was done. Ultrasonography was used to give an accurate assessment of the severity of splenic and concomitant injuries. In stable patients a conservative approach was adopted. RESULTS: In our study 15 patients were managed non-operatively, while 5 underwent splenectomy. Grades I, II, and IIIa spleen injury was significantly associated with non-operative treatment, while grade V was associated with splenectomy (Student-Newman-Keuls test P < 0.05, Mantel-Haenszel chi-square for trend chi 2 = 8.7, P = 0.003). Comparing the non-operative and laparotomy groups, the length of hospital stay (14.0 v. 12.8 days) was similar (t = 1.71, df 18, P > 0.05), while the average blood transfusion volume given was 1.1 units and 3.0 units respectively (t = 3.58, df 18, P < 0.005). CONCLUSIONS: The present study confirms the ability to preserve an increasing number of traumatised spleens by non-operative therapy. This has become possible as a consequence of increasing experience and confidence in pursuing a non-operative approach based on accurate diagnostic methods. Furthermore, non-operative management does not increase the length of stay in hospital and it reduces the total volume of blood transfusions required. While we agree with others that the choice between operative and non-operative management of splenic trauma should be based mainly on clinical grounds, ultrasonography and peritoneal lavage were important tools in the diagnostic pathway and in decision-making. It is worth noting that a 'safe' grade of spleen injury does not exist, since even minor lesions can lead to massive haemoperitoneum and shock requiring emergency splenectomy. In view of the now well known early and late complications after splenectomy, spleen preservation should be the treatment of choice for splenic trauma, especially in tropical countries.

Evaluating diagnosis and treatment of oral and esophageal candidiasis in Ugandan AIDS patients.

A randomized cross-over clinical and endoscopic evaluation of 85 Ugandan patients showed that esophageal candidiasis in AIDS patients with oral candidiasis could be managed without endoscopy and biopsies. Oral lesions, especially when accompanied by esophageal symptoms, were sufficient for diagnosis. Miconazole was more effective than nystatin in treating esophageal candidiasis and could be a valid alternative to more expensive azolic drugs in developing countries.

Clinical and endoscopic aspects of hepatosplenic schistosomiasis in Uganda.

INTRODUCTION: Hepatosplenic schistosomiasis is characterized by hepatic periportal fibrosis (Symmers' fibrosis), portal venous obstruction that leads to portal hypertension and its complications, and splenomegaly. Demonstration of pathological lesions due to Schistosoma mansoni can be achieved by using different techniques but because of its sensitivity, specificity and simplicity, ultrasound has replaced wedge biopsy of the liver as the gold standard for detecting schistosomal periportal fibrosis. The aims of the study were to evaluate clinical aspects of schistosomiasis in a well defined area and to assess whether there was a relationship between the grade of periportal fibrosis and the presence of oesophageal varices and their features. MATERIALS AND METHODS: A total of 122 patients with proven schistosome infection were enrolled in the study. Each underwent ultrasound examination to assess hepatosplenic involvement and staging, and upper digestive endoscopy to assess the presence of oesophageal varices and their features. For all the patients, the main characteristics and symptoms, possibly related to schistosomiasis, were also recorded. RESULTS: A close relationship was found between the grade of periportal fibrosis and the presence of oesophageal varices, their grade and localization in the oesophagus. There was also was a relationship between haematemesis and size of varix, localization of varix and presence of cherry-red spots, but no correlation was found with other endoscopic features of varices. CONCLUSION: Clinical aspects of schistosomiasis in Hoima District are similar to what is known from the literature and there are no specific features. The study shows that ultrasonography is an important tool for accurate staging of hepatosplenic schistosomiasis. Although it cannot replace endoscopy, it can direct the need for performing it. In fact, the higher the grade of periportal fibrosis the greater the possibility of having oesophageal varices. Endoscopy is of value in detecting oesophageal varices especially in advanced stages of liver schistosomiasis, in describing their endoscopic features so as to detect those more at risk of bleeding, and for emergency sclerotherapy.

Clinical aspects and imaging patterns with ultrasonography and endoscopy in hepatosplenic schistosomiasis in Uganda.

In patients with hepato-splenic schistosomiasis, a close relationship between the grade of periportal fibrosis and portal vein diameter, spleen size and presence of oesophageal varices and their grade was found.

Randomized study of antibiotic prophylaxis for general and gynaecological surgery from a single centre in rural Africa.

In a district rural hospital in Uganda, 850 surgical patients were evaluated prospectively over a 3-year period to compare the clinical efficacy of conventional postoperative penicillin therapy with single-dose ampicillin prophylaxis for hernia repair and ectopic pregnancy, and with single-dose ampicillin-metronidazole prophylaxis for hysterectomy and caesarean section. The high rate of postoperative infection usually encountered in African hospitals after conventional treatment with penicillin for 7 days was significantly reduced with the new regimen: from 7.5 to 0 per cent in hernia repair and from 10.7 to 2.4 per cent in ectopic pregnancy; from 20.0 to 3.4 per cent in hysterectomy and from 38.2 to 15.2 per cent in caesarean section. Length of hospital stay and postoperative mortality rates were also significantly reduced. Single-dose ampicillin prophylaxis with or without metronidazole, although rarely used in developing countries, is more cost effective than standard penicillin treatment.

A study of breastfeeding and the return of menses in Hoima District, Uganda.

The effect of breastfeeding on reestablishment of ovulation and fertility and on birth spacing are now well known. A study was conducted on lactational amenorrhoea (LAM) at 180 days in Hoima District, Uganda in order to understand whether and how LAM could be applied in fertility control and birth spacing. Since the introduction of supplementary food by Ugandan women does not replace or substitute for breastfeeding, a study was designed to determine if LAM was effective irrespective of supplementation of infant's diet. One hundred and fifty four mother/child pairs were entered into the study and 134 women completed the sixth month of the study. At the end of the period, eighty four women (62.7%) were amenorrhoeic of whom only 33 (39.3%) were exclusively breastfeeding and no woman had dropped out of the study because of pregnancy or the use of other family planning methods other than LAM. The study confirmed that LAM could be applicable in Uganda to the majority of the breastfeeding women (62.7%). It is expected that if health workers increase the intensity of breastfeeding support as well as the women's knowledge and motivation to use LAM for family planning, this would contribute to children's health as well as to birth spacing that is one of the major factors related to infant deaths. According to data from this study, the return of menses is irrespective of whether supplements have been introduced and their frequency.

Kaposi's sarcoma and AIDS in Uganda: its frequency and gastrointestinal distribution.

The frequency and distribution of gastrointestinal Kaposi's sarcoma were investigated in 63 consecutive AIDS patients. The main risk factor for AIDS was heterosexual intercourse. Gastrointestinal lesions were found in 24 cases (38.1%): 12 patients (11.1%) had both upper and lower GI tract involvement, 7 patients (11.1%) had only oesophago-gastroduodenal lesions and 5 (7.9%) only lower tract disease. Our results show that in heterosexual Africans, the tumours closely resemble the tumours of western homosexuals in endoscopic appearance, in being multicentric and in the gastro-intestinal tract involved. We conclude that even in the heterosexual African AIDS population, the gastrointestinal tract is frequently involved and this phenomenon, if more widely studied might give us new elements about the aetiophatogenesis of Kaposi's sarcoma which is still unclear.

PIP: Acquired immunodeficiency syndrome (AIDS) was first reported in Uganda in 1982. As techniques for detecting AIDS have improved, the number of confirmed cases has increased. Kaposi's sarcoma (KS) has been reported in European studies of AIDS patients at a 34% prevalence rate. These studies mainly focused on homosexuals and intravenous drug users (IVDUs). This study aimed at establishing the frequency, distribution, and endoscopic appearance of gastrointestinal KS in Ugandan heterosexual patients and at verifying whether data published in the western international literature, mainly regarding homosexuals and IVDUs, could be applied to heterosexuals with AIDS. 27 Ugandan men and 36 Ugandan women served as study subjects. All had been diagnosed as AIDS-positive. All patients received complete upper and lower gastrointestinal examinations. The upper digestive tract was examined by oral-endoscopic procedures, while the lower portion was examined using flexible rectosigmoidoscopic techniques. 24 patients (38.1%) had gastrointestinal lesions; 21 of these (87.5%) had multiple lesions. 12 patients (19.1%) had KS involvement of both gastrointestinal areas. Tumors closely resembled those described in studies of homosexuals.

Diagnostic management of epigastric pain in Uganda

180 patients who attended the out patient department of Hoima Hospital (Uganda) complaining of epigastric pain were studied in order to verify the cause and to assess the most effective diagnostic method. All the patients underwent the following examinations: stool examination for parasites; upper digestive tract endoscopy; ultrasound scan of liver; spleen; pancreas and kidneys. The results suggest that the main causes of epigastric pain in Uganda are: intestinal parasitosis (27 per cent); gastrointestinal upper tract lesions with endoscopic signs of disease (44.5 per cent) and non-ulcer dyspepsia (28.4 per cent). The best approach to epigastric pain is first of all to rule out the presence of parasites in the stool. Upper digestive tract endoscopy is useful as a second step in the diagnosis while ultrasound examination does not add important information

Ultrasound in tropical pyomyositis.

Tropical pyomyositis is an infection of muscles mainly presenting in black people, occurring in the trunk and limbs. At Hoima Hospital, Uganda, 58 patients (30 men and 28 women) with a mean age of 21 years have been investigated by ultrasound; a total of 81 lesions were present. Two different characteristic images were found; abscess was present in 65 cases while 16 patients showed a diffuse infiltration among the muscular fibers. These two different images correspond to the two stages of histologic and clinical progression described by other authors. Ultrasound is useful to demonstrate the progression of pyomyositis and to determine when and where to drain any abscess.