Role of quetiapine in protection of neurodegeneration after traumatic brain injury.

Objective: Schizophrenia is a chronic psychotic disorder in which patients experience positive and negative symptoms for over six months. Schizophrenia is associated with early mortality, with 40% of this excess mortality due to suicide. This is a case of patient with schizophrenia who was treated with quetiapine after suffering a traumatic brain injury and recovered enough to be discharged to a rehabilitation unit. This case illustrates the neuroprotective effects of quetiapine in treating neurologic deficits in a patient who recently suffered a traumatic brain injury. Method: This is a case report of a patient with schizophrenia treated in the hospital setting. He was placed on quetiapine after suffering a traumatic brain injury due to a suicide attempt in which he shot himself with a nail gun. Results: The patient initially presented with neurologic deficits suggestive of traumatic brain injury (inattention, memory loss, muscle weakness) and psychosis from schizophrenia. He was treated with quetiapine and recovered enough to be discharged to a rehabilitation unit. Conclusion: Quetiapine, a second-generation antipsychotic, has been shown to significantly decrease blood­brain barrier hyperpermeability by preserving tight junction integrity in small animal models. This anti-inflammatory effect may also help to preserve neurogenesis in patients with traumatic brain injury, as shown in this case. This case may help elucidate the nature of quetiapine's neuroprotective effects in patients who have suffered traumatic brain injury and also highlights the need to further investigate other atypical antipsychotics and their potential neuroprotective role in treating traumatic brain injury.

Surgical Residency Training in Developing Countries: West African College of Surgeons as a Case Study.

BACKGROUND: In 1904, William Halsted introduced the present model of surgical residency program which has been adopted worldwide. In some developing countries, where surgical residency training programs are new, some colleges have introduced innovations to the Halsted's original concept of surgical residency training. These include 1) primary examination, 2) rural surgical posting, and 3) submission of dissertation for final certification. STUDY DESIGN: Our information was gathered from the publications on West African College of Surgeons' (WACS) curriculum of the medical schools, faculty papers of medical schools, and findings from committees of medical schools. Verbal information was also gathered via interviews from members of the WACS. Additionally, our personal experience as members and examiners of the college are included herein. We then noted the differences between surgical residency training programs in the developed countries and that of developing countries. RESULTS: The innovations introduced into the residency training programs in the developing countries are mainly due to the emphasis placed on paper qualifications and degrees instead of performance. CONCLUSION: We conclude that the innovations introduced into surgical residency training programs in developing countries are the result of the misconception of what surgical residency training programs entail.

Seeing double: sertraline and diplopia: a case report.

OBJECTIVE: To describe the first case of sertraline-induced diplopia. METHOD: Medline and PubMed data search using the words sertraline, Zoloft, diplopia, double vision. A case summary of a patient who developed diplopia from sertraline. RESULT: This case describes a 34-year-old man who developed diplopia after treatment with sertraline. The diplopia resolved after discontinuation of sertraline and redeveloped upon rechallenge. CONCLUSION: Although incidences of diplopia caused by citalopram, another SSRI, have been described, to the best of our knowledge, this is the first reported case of sertraline-induced diplopia. More studies are needed to describe the full mechanism of action of sertraline-induced diplopia.

The use of clonidine in the treatment of nightmares among patients with co-morbid PTSD and traumatic brain injury.

OBJECTIVE: To describe the successful treatment of PTSD associated nightmares in two patients with PTSD. CASE SUMMARIES: The report of the successful use of clonidine to treat PTSD associated nightmares among two Veterans following combat exposure. DISCUSSION: Clonidine, a centrally acting alpha-agonist agent used to treat hypertension, stimulates alpha-adrenoreceptors in the brain stem. This action results in reduced sympathetic outflow from the central nervous system. We hypothesize that this central mechanism of action is why clonidine may be more effective in treating nightmares among patients with PTSD when compared with other agents. CONCLUSION: Clonidine should be considered as an alternative in the treatment of nightmares among patients with PTSD.

Neuropsychiatric systemic lupus erythematosus presenting as bipolar I disorder with catatonic features.

BACKGROUND: The American College of Rheumatology has defined 19 neuropsychiatric syndromes associated with systemic lupus erythematosus (SLE) involving the central, peripheral, and autonomic nervous systems. Neuropsychiatric manifestations of lupus (NPSLE) have been shown to occur in up to 95% of pediatric patients with SLE. OBJECTIVE: The authors describe a 15-year-old African American young woman with a family history positive for bipolar I disorder and schizophrenia, who presented with symptoms consistent with an affective disorder. METHOD: The patient was diagnosed with Bipolar I disorder with catatonic features and required multiple hospitalizations for mood disturbance. Two years after her initial presentation, the patient was noted to have a malar rash and subsequently underwent a full rheumatologic work-up, which revealed cerebral vasculitis. RESULTS: NPSLE was diagnosed and, after treatment with steroids, the patient improved substantially and no longer required further psychiatric medication or therapy. CONCLUSION: Given the especially high prevalence of NPSLE in pediatric patients with lupus, it is important for clinicians to recognize that neuropsychiatric symptoms in an adolescent patient may indeed be the initial manifestations of SLE, as opposed to a primary affective disorder.

Valacyclovir-induced psychosis and manic symptoms in an adolescent young woman with genital herpes simplex.

BACKGROUND: Genital herpes is a common and painful infection. Its prevalence within the United States is estimated to be 40 million to 60 million people. Three medications, acyclovir, valacyclovir, and famciclovir, have been shown to reduce the duration and severity of the disease. OBJECTIVE: The authors report on the first known case of valacyclovir-induced psychosis with symptoms of mania in a young woman with no previous psychiatric history. METHOD: The patient presented with irritable mood and grandiose delusions 72 hours after starting valacyclovir for genital herpes. Valacyclovir treatment was stopped, and risperidone was initiated. RESULTS: The symptoms continued after stopping the valacyclovir, but improved with risperidone. DISCUSSION: There are reports of neuropsychiatric side effects with valacyclovir's structural analogs in elderly patients with renal dysfunction. Clinicians should be aware that valacyclovir may induce psychosis with manic presentation in young, healthy patients without a psychiatric history.

Aripiprazole and delirium.

BACKGROUND: Delirium is a common condition frequently seen in consultation-liaison psychiatry. It is especially common among medically compromised patients and is an indicator of the severity of the medical illness. In addition, it is associated with a higher morbidity, mortality or longer hospitalization. Traditionally, haloperidol has been used to treat delirium-associated agitation. However, atypical antipsychotics are being increasingly used to treat delirium. METHODS: Two case studies of delirium that were treated with 30 mg and 15 mg aripiprazole were described. The improvement of delirium was monitored using the Mini-Mental Status Exam (MMSE) and Delirium Rating Scale (DRS). RESULTS: In both cases, the patients' confusion, disorientation, and agitation improved within 7 days of treatment. In the first case, the patient's MMSE score improved from 5 to 28, while his DRS score decreased from 28 to 6. In the second case, her MMSE score improved from 7 to 27, while her DRS score went down from 18 to 6. CONCLUSIONS: To the best of our knowledge, this is the first report on the utilization of aripiprazole in the successful treatment of delirium. Although these cases showed positive results, future studies should be performed in order to further substantiate its use in delirium treatment.

Cybersuicide: review of the role of the internet on suicide.

The internet as a widespread source of communication is already having a significant influence in medicine and psychiatry. Although the internet has great potential in psychiatric education, clinical care, and research, its impact on social issues should not be underestimated. Firstly, the internet as a means of communication may encourage suicidal behavior by depicting ways by which suicide may be committed. Secondly, some internet websites may discourage people with mental illness from seeking psychiatric help, condone suicide, and forbid entry to anyone offering to discourage users from committing suicide. However, the internet could be a resource to help a potentially suicidal person get help, and can be used to identify those at risk for suicide, communicate with them, and potentially prevent suicide. If used appropriately, the internet is a powerful communication tool that can be used to benefit suicidal patients.

Aripiprazole in the treatment of delirium.

OBJECTIVE: Delirium is a common condition frequently seen in consultation-liaison psychiatry. It is especially common among medically compromised patients, and is an indicator of the severity of the medical illness. In addition, it is associated with a higher morbidity, mortality, and longer hospitalization. Traditionally, haloperidol has been used to treat agitation as it may occur in delirium. However, atypical antipsychotics are being increasingly used to treat delirium. METHOD: In this article, we will describe two cases of delirium successfully treated with aripiprazole. RESULTS: Both patients had significant improvement in their delirium as measured by the delirium rating scale. CONCLUSION: Aripiprazole appears to be effective in reducing the symptoms of delirium.

An unusual foreign body ingestion in a schizophrenic patient: case report.

The topic of foreign body ingestion has received extensive coverage in the areas of surgery, emergency medicine, and pediatrics. A subset of this topic, the intentional ingestion of foreign bodies, however, is much less common, and requires special evaluation and management. Here, we report a case of ingestion of a rolled, metal tuna can lid in a male prison inmate previously diagnosed with depression and paranoid schizophrenia. Following evaluation by the surgical team, the foreign body was removed by laparotomy and the patient was discharged back to the prison without complication. In many cases, ingestions of this type involve a command hallucination ordering the patient to swallow the foreign body. Interestingly, the patient in the present case reported auditory hallucinations commanding him not to swallow the can lid. On further investigation, we found that patient had a proclivity toward this swallowing behavior even prior to his incarceration. Early identification of inmates with this proclivity has important implications for treatment and prevention.

Charles Bonnet syndrome: visual hallucination and multiple sclerosis.

Multiple sclerosis (MS) is a fairly common condition that affects approximately 350,000 people in the United States. It is associated with various neuropsychiatric symptoms including cognitive and behavioral symptoms. However, visual hallucinations are rare in multiple sclerosis without the presence of cognitive deficits. We are describing the case of a 40-year-old married white female with isolated complex visual hallucinations compatible with the Charles Bonnet syndrome (CBS). The patient was successfully treated with the atypical antipsychotic olanzapine.

Drug addiction in sickle cell disease: case report.

There has been widespread speculation that patients with sickle cell disease (SCD) may become drug dependent if their painful crisis is treated with narcotics. However, there has been no scientific evidence to support this assertion. Paradoxically, individuals suffering from sickle cell disease who are not adequately treated may develop an addiction to narcotics due to self-medication to treat their pain. In this article, we describe a 38-year-old African American woman who became addicted to cocaine due to self-medication of her sickle cell pain with cocaine.

ECT in the medically ill elderly: a case report.

Electroconvulsive therapy (ECT) is well recognized as an effective treatment for depression. However, it is not often used among the elderly due to increased co-morbid medical problems and fear of complications. We present here the case of an 88-year-old man with a history of depression and co-morbid medical illness. This patient was successfully treated with ECT. With the population of individuals above the age of 65 expected to double in the next 40 years, the use of ECT to treat major depression and other psychiatric conditions among the elderly will likely increase.

Sickle cell disease and posttraumatic stress disorder.

Sickle Cell Disease (SCD) is a common condition among African Americans. It is associated with severe complications including severe pain in the chest, back, abdomen, or extremities. Individuals with SCD also have a reduced life span. Post traumatic stress disorder (PTSD) is a condition increasingly being recognized. In this article we discuss, to our knowledge, the first case of a patient with comorbid sickle cell disease and post-traumatic stress disorder.

Comparing the side effect profile of the atypical antipsychotics.

Typical antipsychotics exert their effect by blocking post-synaptic dopaminergic receptors; blockade of the mesolimbic and mesocortical pathways are therapeutic and help reduce positive psychotic symptoms but blockade of the nigro-striatal pathway produces extrapyramidal side effects (EPSE). Post clozapine, the Food and Drug Administration (FDA) has approved the use of four newer atypical antipsychotics; risperidone, olanzapine, quetiapine and ziprasidone for the treatment of schizophrenia. Because of their dual serotonin and dopamine receptor blocking abilities, atypical antipsychotics have greater efficacy (especially for negative symptoms) and fewer EPSE when compared to the typical antipsychotics. Given the lack of studies directly comparing these agents, we used the Physician Desk Reference (PDR) to calculate the treatment emergent placebo adjusted side effects for these atypical antipsychotics. The results are then presented in an easy to read table. To the best of our knowledge, this is the first comparison study involving these four newer antipsychotic agents.