A literature therapeutic group at a psychiatric closed-unit

Introduction

This lecture will present a therapeutic group that took place at a closed-unit in a psychiatric hospital. The members of this group were patients suffering from psychotic disorders

Objectives

Patients suffering from psychotic disorders.

Methods

The patients had difficulty in organizing their thoughts as well as with the expression of their internal-world and emotions. Moreover, they were suspected of the units’ staff members. These circumstances led us to create a theme group that combines a verbal-affective metaphoric instrument - literature. Art, such as literature, represents the mind of its creator and when incorporated into the therapeutic process, can serve as a third-voice - a symbolic language that conveys an idea indirectly and arouses the patient’s personal associations and emotions. The use of literature, while relating to content that aroused from a poem or a short story, led to a connection or an identification with the emotion expressed in the writing stimuli or in opposition to it, and from there to a projection of the internal world of the patient.

Results

Through the possibility of alternating between proximity and distance, regard the metaphoric instrument, patients could organize their associations and emotions and express them in a more beneficent way – “normalization” of the cognitive and expressive process.

Conclusions

The analysis of the different group’s sessions, points to the potential of using literature in a therapeutic group with patients in their acute state, at the closed-unit. Examples of verbal reports from different group settings, in which literature was used, will be presented.

Disclosure

No significant relationships.

Differential Effect of Community Rehabilitation Reform on Hospitalizations of Patients with Chronic Psychotic Disorders With and Without Substance Use Disorder, Israel, 1991-2016

The co-occurrence of schizophrenia and substance use disorder (SUD) is clinically challenging and increasingly prevalent. This study compares trends in hospitalization characteristics of chronic psychotic patients with and without SUD in Israel, before and after introduction of the Community Rehabilitation of Persons with Mental Disability Law in 2000. The National Psychiatric Case Registry provided data on 18,684 adults with schizophrenia/schizoaffective disorders, hospitalized in 1991-2016 (at least once in 2010-2015). Repeated-measures ANOVA was used to measure the effect (and interactions) of group (patients with and without co-occurring disorders (COD)), time-period (Period₁: 1991-2000, Period₂: 2001-2009, Period₃: 2010-2016) and age, on hospitalization measures-average length of stay (LOS), annual number of hospitalizations and hospitalization days. Among non-COD patients hospitalized in all three periods, LOS declined by half from 133.3 days in Period₁ to 63.2 in Period₃, and the annual number of hospitalizations increased slightly from 0.45 to 0.56. Among COD patients, LOS declined moderately from 82.7 days to 58.3 days, while annual hospitalizations increased dramatically from 0.56 to 0.82. The annual average number of hospitalization days/capita declined from 49.7 in Period₁ to 26.3 in Period₃ among non-COD patients, yet remained virtually unchanged among COD patients-39.6 and 37.4 in the two periods, respectively. Since introduction of the law, a significant improvement in hospitalization characteristics of chronic psychotic non-COD patients has been noted, whereas the situation worsened somewhat for COD patients. Community rehabilitation services for COD patients in Israel have yet to develop as a suitable alternative to hospitalization, and additional rehabilitation services are urgently needed.

Psychiatric Hospitalizations of Chronic Psychotic Disorder Patients With and Without Dual Diagnosis, Israel, 1963-2016

Objective: A significant proportion of patients with severe mental illness also experience substance use disorder. For these dual diagnosis (DD) patients, treatment is more complicated and prognosis is worse. Despite the introduction of the Community Rehabilitation of Persons With Mental Health Disability Law in 2000 and ongoing national mental health reforms, psychiatric services in Israel are not meeting the needs of an increasing number of DD patients. This study examines, for the first time in Israel, the prevalence of DD and patterns of psychiatric hospitalizations of chronic psychotic disorder patients with and without substance use disorder. Methods: The National Psychiatric Case Registry provided data on 18,684 persons with schizophrenia/schizoaffective disorders, aged 18-65, with a psychiatric hospitalization during the period 1963-2016 (with at least one hospitalization in 2010-15). Patients were considered as having DD if their substance use disorder was indicated in at least two, or 20%, of hospitalizations. Regression modeling predicted hospitalization measures (number of hospitalizations, total days hospitalized, length of stay). Results were also analyzed by legal status of admission (voluntary or involuntary; psychiatrist-ordered and court-ordered). Results: One-third of patients with chronic psychotic disorder met DD criteria, with a threefold higher rate among males (37.1%) than females (12.8%). Particularly high rates of DD (nearly 50%) were noted among male immigrants from Ethiopia. Compared with non-substance use disorder patients, DD patients had a significantly younger mean age at first hospitalization and shorter average length of stay per hospitalization but a greater number of hospitalizations and total hospital days (p < .0001 for all comparisons). The associations between DD status and hospitalization characteristics remained significant even after accounting for the effects of confounding factors. Hospitalization characteristics were also associated significantly with sex, population group, age, age at first hospitalization, and country of origin. The rate of court-ordered observation or hospitalization was threefold higher in the DD group. Conclusions: These findings, which broadly align with other countries, reflect a scarcity of outpatient services for DD patients with schizophrenia/schizoaffective disorder and substance use disorder. To achieve long-term mental health improvements, an expansion of community-based integrative treatment and rehabilitation services is needed in Israel.

The eicosapentaenoic acid:arachidonic acid ratio and its clinical utility in cardiovascular disease

Eicosapentaenoic acid (EPA) is a key anti-inflammatory/anti-aggregatory long-chain polyunsaturated omega-3 fatty acid. Conversely, the omega-6 fatty acid, arachidonic acid (AA) is a precursor to a number of pro-inflammatory/pro-aggregatory mediators. EPA acts competitively with AA for the key cyclooxygenase and lipoxygenase enzymes to form less inflammatory products. As a result, the EPA:AA ratio may be a marker of chronic inflammation, with a lower ratio corresponding to higher levels of inflammation. It is now well established that inflammation plays an important role in cardiovascular disease. This review examines the role of the EPA:AA ratio as a marker of cardiovascular disease and the relationship between changes in the ratio (mediated by EPA intake) and changes in cardiovascular risk. Epidemiological studies have shown that a lower EPA:AA ratio is associated with an increased risk of coronary artery disease, acute coronary syndrome, myocardial infarction, stroke, chronic heart failure, peripheral artery disease, and vascular disease. Increasing the EPA:AA ratio through treatment with purified EPA has been shown in clinical studies to be effective in primary and secondary prevention of coronary artery disease and reduces the risk of cardiovascular events following percutaneous coronary intervention. The EPA:AA ratio is a valuable predictor of cardiovascular risk. Results from ongoing clinical trials will help to define thresholds for EPA treatment associated with better clinical outcomes.

Congenital bilateral absence of the vas deferens as an atypical form of cystic fibrosis: reproductive implications and genetic counseling

Congenital bilateral absence of the vas deferens (CBAVD) is found in 1% to 2% of males with infertility and is present in 6% of obstructive azoospermia cases. Nearly 95% of men with cystic fibrosis (CF, an autosomal recessive disorder) have CBAVD. There are genetic links between CBAVD and CF. Some mutations in the gene encoding cystic fibrosis transmembrane conductance regulator (CFTR) can lead to CBAVD as a monosymptomatic form of CF. With the use of assisted reproductive techniques (ART), especially testicular or epididymal sperm aspiration, intracytoplasmic sperm injection, and in vitro fertilization, it is possible that men with CBAVD can produce offspring. Therefore, genetic counseling should be offered to couples undergoing ART to discuss the probability of having offspring that carry CFTR gene mutations. The aim of this review was to present the main cause of CBAVD, to call attention to its implications for assisted reproduction, and to show the importance of genetic counseling for couples where men have CBAVD, as they can have offspring with a lethal disease.

Pitfalls in diagnosing colon cancer on abdominal CT

AIM

To assess the frequency of undetected colon cancer on conventional abdominal CT and to evaluate the imaging features that are characteristic of those cancers.

MATERIALS AND METHODS

The present study included consecutive patients diagnosed with colorectal cancer at colonoscopy (2006-2015) who also underwent abdominal computed tomography (CT) performed for various reasons within a year prior to the colonoscopy. The frequency of undetected lesions was evaluated for the original CT interpretations ("original readers"). Two radiologists ("study readers"), blinded to the tumour location, independently performed interpretations oriented for colon cancer detection. The study readers analysed the imaging features of detected tumours (tumour shape, length, maximal wall thickness, free fluid, fat stranding, vascular engorgement, stenosis, and lymphadenopathy). Imaging features of the cancers undetected by the original readers were evaluated.

RESULTS

The study included 127 patients. The original readers' frequency of undetected cancer was 25/127 (19.7%). Each study reader could not identify the cancer in 8/127 (6.3%) patients. Imaging features associated with undetected cancers by the original readers included the absence of fat stranding (p=0.007, p=0.003), absence of vascular engorgement (p<0.0001, p<0.0001) and absence of lymphadenopathy (p=0.005, p=0.004). Undetected tumours were shorter than those detected (original reader: 33.2±11.9 versus 51.4±18.2 mm; study reader: 32.5±9.6 versus 61.3±23.4 mm; p<0.001).

CONCLUSION

Colon cancer is undetected in 20% of abdominal CT examinations in patients subsequently proven to have colon cancer at colonoscopy. The absence of fat stranding, vascular engorgement, or lymphadenopathy, and an average tumour length of 3.3 cm are contributing factors for failure of detection. Radiologists' training should emphasis these findings as it may improve cancer detection, and clinicians should be aware of the limitations of abdominal CT.

Three-dimensional analysis of craniofacial bones and soft tissues in obstructive sleep apnea using cone beam computed tomography

A total of 154 adult patients with sleep complaints underwent a polysomnography and a craniofacial cone beam computed tomography (CBCT). OSA was defined as an apnea and hypopnea index (AHI) or an oxygen desaturation index (ODI) ≥ 10. Soft tissues and craniofacial bones volumes were prospectively measured by CBCT and collected blindly from sleep polysomnography. Among the study patients, 127 (83%) suffered from OSA and 27 (17%) did not. OSA patients demonstrated a narrower maxillo-palatine core volume (11.7±3.2 vs 14.6±4.9cm³) even when adjusting for age, gender, height, neck circumference and body mass index. These upper airway measures provide a comprehensive analysis of bony structures and soft tissues, which can be involved in OSA.

Kohlschütter-Tönz syndrome in siblings without ROGDI mutation

BACKGROUND

Kohlschütter-Tönz syndrome is a rare neurodegenerative disorder presenting with intractable seizures, developmental regression, and characteristic hypoplastic dental enamel indicative of amelogenesis imperfecta. Recently, mutations in ROGDI were identified in part of Kohlschütter-Tönz syndrome cases, but the siblings reported here do not have a mutation in the ROGDI gene, showing that there is genetic heterogeneity in Kohlschütter-Tönz syndrome.

AIM

Report two siblings that have Kohlschütter-Tönz syndrome.

CONCLUSION

Early onset of seizures and lack of the ability to walk without support may be signs of non-ROGDI mutations in Kohlschütter-Tönz syndrome patients.

Wavelet analysis of the frontal auditory evoked potentials obtained in the passive oddball paradigm in healthy subjects and schizophrenics

The goal of the present study was to apply the oscillatory brain dynamics model to the structural and quantitative analysis of neurocognitive functions considered as a potential marker of schizophrenia. This was achieved in tests of the detection of auditory events deviating in the regular auditory stream (oddball paradigm, MMN effect). It was hypothesized that the post-stimulus peaks of the oscillation power localized in post-stimulus time in the definite EEG oscillators represented neuro-electrical 'events' evoked in the specific neuronal nets characterized by this oscillation frequency band. We suggest that the time-frequency destination of these events related to the activation of the functional neuronal nets could be used for the determination of specific neurocognitive functions. Thus it was an attempt to distinguish the different neuro-functional parts of auditory processing and to compare these results between healthy subjects and patients with schizophrenia. The present results demonstrate the significant difference between the frontal averaged EEG oscillatory dynamics in healthy subjects and patients with schizophrenia related to neurocognitive function marked by the MMN and orienting response N200/P300a.

Treatment of a child diagnosed with Niemann-Pick disease type C with miglustat: a case report in Brazil

Niemann-Pick disease type C (NPC) is an autosomal recessive neurovisceral lysosomal lipid storage disorder that leads to variable symptoms that include cognitive decline, ataxia, dystonia, cataplexy, vertical supranuclear gaze palsy, and seizures. Currently, there is no specific treatment for NPC other than palliative care. Substrate reduction therapy represents a potential strategy for treating this debilitating neurodegenerative disorder. Miglustat (Zavesca) is a reversible inhibitor of the enzyme glucosylceramide synthase, which catalyses the first step in the biosynthesis of most glycosphingolipids. Miglustat has pharmacokinetic properties that allow it to cross the blood-brain barrier, thus making it a potential therapeutic agent for treating neurological symptoms in NPC patients. We present here a case report of a Brazilian child treated with miglustat. Before treatment, the patient presented with difficulties walking and swallowing, slurred speech, moderate cognitive impairments, ataxia, ptosis, and vertical supranuclear ophthalmoplegia. On a disability scale, the patient obtained a score of 15 before treatment and 8 after treatment. Following 12 months of treatment, the patient remained stable with improvements in speech, ptosis, ophthalmoplegia, ataxia, hypotonia and seizures. The Child Behavior Checklist (CBCL) was used to assess psychopathological, behavioural and social problems before and after treatment. The CBCL showed that indices for depression, affective and attention problems were all in the normal range following treatment. Thus, for this individual miglustat was an effective, well-tolerated and efficacious medication for treatment of NPC symptoms. Follow-up maintenance studies are vital to establish whether both the efficacy and safety of miglustat persist with time.

Cystic fibrosis in a southern Brazilian population: characteristics of 90% of the alleles

Cystic fibrosis (CF) is a genetic disease that frequently leads to death in infancy among Europeans and their descendants. The goals of the present study were to analyze the molecular aspects of CFTR gene characterizing mutations, their frequencies, and the haplotypes formed by four CFTR gene intragenic markers, IVS8-6(T)n, IVS8CA, IVS17bTA and IVS17bCA, in a southern Brazilian population of Caucasian origin. DNA samples from 56 non-related CF patients were analyzed using scanning techniques (single strand conformation polymorphism and denaturing gradient gel electrophoresis), restriction fragment length polymorphism and direct DNA sequencing to identify the mutations. Our results revealed a total of 25 different CF mutations representing nearly 90% of CF alleles, two being novel mutations. Microsatellite haplotypes were defined for CF and normal alleles. The mutational spectrum and the associated haplotypes described for the first time in this study should prove relevant for genetic counselling and CF population screening in Brazil. Moreover, our results suggest the presence of a major Mediterranean component in the contemporary Brazilian CF patient pool.

Cystic fibrosis gene variability in two southern Brazilian Amerindian populations: analysis of the deltaF508 mutation and the KM19 and XV2C haplotypes

The frequencies of the deltaF508 deletion, the most common cystic fibrosis mutation in Europeans and European-derived populations, and the XV2C and KM19 restriction fragment length polymorphisms that are tightly linked to the CFTR locus vary among populations. To determine the distribution of these extragenic markers and of the deltaF508 mutation, we analyzed 326 chromosomes of individuals from two South American Indian populations, the Guarani and the Kaingang. The allele and haplotype frequencies differed greatly between the two populations as well as among Amerindians and normal European Brazilians and European Brazilian cystic fibrosis patients. The absence of the deltaF508 mutation and the B haplotype are in agreement with the hypothesis that the deltaF508 mutation occurred after the divergence of these two populations. This finding is useful for populations containing a large Amerindian component and helps us to understand the origins of the deltaF508 deletion, the most common cystic fibrosis mutation in Europeans and European-derived populations, as well as the different incidences of cystic fibrosis in continental groups.

Clinical phenotype of Brazilian families with spinocerebellar ataxia 10

Spinocerebellar ataxia type 10 (SCA10) is an autosomal dominant ataxia caused by an ATTCT repeat expansion in an intron of the SCA10 gene. SCA10 has been reported only in Mexican families, in which the disease showed a combination of cerebellar ataxia and epilepsy. The authors report 28 SCA10 patients from five new Brazilian families. All 28 patients showed cerebellar ataxia without epilepsy, suggesting that the phenotypic expression of the SCA10 mutation differs between Brazilian and Mexican families.

Three cases with rare interstitial rearrangements of chromosome 1 characterized by multicolor banding

In this report, we describe three unrelated patients with similar symptoms such as mental retardation, growth delay and multiple phenotypic abnormalities. GTG-banding analysis revealed karyotypes with add(1p) in two cases and an add(1q) in the third. Fluorescence in situ hybridization (FISH) analysis using high resolution multicolor banding (MCB) characterized the aberrations of the abnormal chromosomes 1 as a (sub)terminal duplication and inverted duplications, respectively. Although three different chromosomal regions i.e. 1p36.1, 1p36.2-->1p31.3 and 1q41-->1q44 were involved, all three patients had similar patterns of dysmorphic findings. These cases demonstrate the power of MCB in the characterization of small interstitial chromosomal aberrations and resulted in the characterization of three previously unreported congenital chromosome 1 rearrangements.

Generalized dystonia and striatal calcifications with lipoid proteinosis

Lipoid proteinosis (LP) is an autosomal recessive disease that typically presents with papular, verrucous, poxlike, or acneiform scars and lesions and hoarseness. LP was recently mapped to the 1q21 locus and shown to result from mutations in the extracellular matrix protein 1 gene (ECM1). Epilepsy, mental retardation, and hippocampal calcifications can occur. The authors describe a patient with generalized dystonia caused by striatal calcifications.

[The sleep obstructive apnea and hypopnea syndromes]

Since two decades, sleep breathing disorders are more wisely recognized by the Belgian medical community. Among these, the Obstructive Sleep Apnea Syndrome (OSA) is the best known but its frontiers with others syndromes such as the Upper Airway Resistance Syndrome (UARS), the Central Sleep Apnea Syndrome (CSAS) or the Overlap Syndrome are still matter of discussion. Its causes are plurifactorial, and many recent publications draw the attention to its long term effects in the cardiovascular and neuropsychiatric fields. This article summarizes the present definitions and features associated with OSA, from clinical and neurophysiological perspectives, and the different consequences to which untreated or underdiagnosed patients are exposed.

[Vertical dimension in the OSAHS in adults: an example of functional alteration]

Obstructive sleep apnea and hypoapnea syndrome (OSAHS) is important to orthodontists for several reasons. The authors, after defining OSAHS and describing it briefly, review the literature dealing with the cranio-facial morphology of apnea patients. They report the results of their cephalometric study, which is based on an architectural analysis of 274 patients. Their facial characteristics, especially vertical dimension, are consistent with those displayed by mouth breathing children. Changes in respiratory functioning modify the mechanical behavior and the structures of the upper airways. Osseous tissues also show signs caused by these changes. The authors propose an etiopathogenic model.

New parkin mutations and atypical phenotypes in families with autosomal recessive parkinsonism

The frequency of parkin mutations was evaluated in 30 families of highly diverse geographic origin with early-onset autosomal recessive parkinsonism. Twelve different mutations, six of which were new, were found in 10 families from Europe and Brazil. Patients with parkin mutations had significantly longer disease duration than patients without the mutation but with similar severity of disease, suggesting a slower disease course. Two patients with parkin mutations had atypical clinical presentation at onset, with predominant tremor when standing.

[Our experience with geniopexy in the treatment of OSAS]

OBJECTIVE

We examine geniopexy efficacy in OSAS treatment.

STUDY DESIGN

Seven patients, aged 36 to 61 years, were studied. The mean body mass index was normal.

RESULTS

Surgical late complications (modified symphysis proprioception) occurred in 4 patients. No patient was improved in sleep problems. Retromaxilly and retromandibuly were found in all patients by cephalometric study.

DISCUSSION

Our results are quite different from these described successfully by other centers. Geniopexy do not move maxillar and mandibular skeletal bones, which are retruded in our serie. This explains maybe our bad results. Actually, we propose for this patients maxillo-mandibular advancement.

Surgical management of maxillomandibular advancement in sleep apnea patients: specific technical considerations

Maxillomandibular advancement is an integral part of the surgical treatment of patients suffering from obstructive sleep apnea. A number of publications report its efficacy and have attempted to define predictive success criteria. However, few authors have shown an interest in the surgical specificity of this intervention and in the difficulties that can be encountered, which differ from those seen in conventional orthognathic surgery. In this article, a series of patients treated with maxillomandibular osteotomy to correct obstructive sleep apnea syndrome (n = 17) are compared with patients who underwent surgery for the correction of dentofacial disharmonies (n = 33). Observations emphasized the importance of respecting a strict surgical and postsurgical protocol to avoid any technical traps linked to maxillomandibular advancement, both in preoperative simulations and during and after surgery. Results concerning sleep parameters will be the subject of a future publication.

[Cephalometric assessment in obstructive sleep apnea and hypopnea syndrome]

Several cephalometric studies have been published to study sleep apnea and hypopnea. The purpose of this review is to provide a clear analysis of the different and apparently contradictory cephalometric results and to describe certain pitfalls of the method. In general, an excessive development of the tongue and soft palate are observed in these subjects, limiting the pharyngeal airway. Bony anomalies include mandibular retrognathism and an excessive anterior ventral development of the skull associated with insufficient anterior growth of the base of the skull. The head is held in extension. These different factors contribute to blocking the upper airway and favor pharyngeal collapse. Cephalometry can be used to identify patients at risk and to propose an apnea/hypopnea index for precise etiological diagnosis and therapeutic decision making.

The G209A mutation in the alpha-synuclein gene in Brazilian families with Parkinson's disease

A missense G209A mutation of the alpha-synuclein gene was recently described in a large Contursi kindred with Parkinson's disease (PD). The objective of this study is to determine if the mutation G209A of the alpha-synuclein gene was present in 10 Brazilian families with PD. PD patients were recruited from movement disorders clinics of Brazil. A family history with two or more affected in relatives was the inclusion criterion for this study. The alpha-synuclein G209A mutation assay was made using polymerase chain reaction and the restriction enzyme Tsp45I. Ten patients from 10 unrelated families were studied. The mean age of PD onset was 42.7 years old. We did not find the G209A mutation in our 10 families with PD. Our results suggest that alpha-synuclein mutation G209A is uncommon in Brazilian PD families.

Congenital contractural arachnodactyly with neurogenic muscular atrophy: case report

We report the case of a 3-(1/2)-year-old girl with hypotonia, multiple joint contractures, hip luxation, arachnodactyly, adducted thumbs, dolichostenomelia, and abnormal external ears suggesting the diagnosis of congenital contractural arachnodactyly (CCA). The serum muscle enzymes were normal and the needle electromyography showed active and chronic denervation. The muscle biopsy demonstrated active and chronic denervation compatible with spinal muscular atrophy. Analysis of exons 7 and 8 of survival motor neuron gene through polymerase chain reaction did not show deletions. Neurogenic muscular atrophy is a new abnormality associated with CCA, suggesting that CCA is clinically heterogeneous.

Huntington disease: DNA analysis in Brazilian population

Huntington disease (HD) is associated with expansions of a CAG trinucleotide repeat in the HD gene. Accurate measurement of a specific CAG repeat sequence in the HD gene in 92 Brazilian controls without HD, 44 Brazilian subjects with clinical findings suggestive of HD and 40 individuals from 6 putative HD families, showed a range from 7 to 33 repeats in normal subjects and 39 to 88 repeats in affected subjects. A trend between early age at onset of first symptoms and increasing number of repeats was seen. Major increase of repeat size through paternal inheritance than through maternal inheritance was observed. Data generated from this study may have significant implications for the etiology, knowledge of the incidence, diagnosis, prognosis, genetic counseling and treatment of HD Brazilian patients.

Risperidone in treating behavioural disturbances of Prader-Willi syndrome

OBJECTIVE

This paper reports the results of risperidone treatment in seven patients (six adults and one adolescent) diagnosed as suffering from Prader-Willi syndrome (PWS) accompanied by severe behavioural disturbances. Risperidone was chosen following the failure of these patients to respond to other acknowledged modes of treatment for the psychiatric manifestations of PWS.

METHOD

This was a prospective open-label study. Measures of Clinical Global Impression Scale (CGIS), Retrospective Overt Aggression Scale (ROAS), Aggression Score (AS) and weight were obtained during two baseline visits and again following 37 weeks of treatment with risperidone.

RESULTS

Low dosages (1-3 mg/day; 1.6 mg/day on average) of risperidone brought about notable clinical improvement with no apparent adverse side effects. All measures evaluated--general behaviour, CGIS, OAS and weight--reacted favourably to the treatment protocol.

CONCLUSION

The preliminary results presented here suggest that risperidone is useful in treating PWS due to its positive effect on the disruptive behavioural symptoms that accompany it.

[Indications and implications of surgical maxillary expansion in orthodontic surgery]

Surgically assisted rapid maxillary expansion is an accepted method for correction of transverse skeletal and dental discrepancies. The surgical technique includes a Lefort I osteotomy with medial palatine osteotomy. The maxillary must be totally released to achieve the desired expansion. There are several advantages: bone apposition in osteotomy sites, reduced risk of dental version or extrusion compared with orthopedic care, secondary surgical cure of complex dysmorphism requiring fewer segmentary osteotomies. Finally, we examined skeletal side effects induced by surgically assisted rapid maxillary expansion in the vertical and sagittal dimension of the face.

Olanzapine and sulpiride: a preliminary study of combination/augmentation in patients with treatment-resistant schizophrenia

Coadministration of olanzapine, an atypical neuroleptic, with sulpiride, a selective D2 antagonist, is suggested as an efficient strategy for treating patients with resistant unremitting schizophrenia. The psychopharmacologic rationale that may account for the enhanced clinical efficacy of combining sulpiride with olanzapine and vice versa is the difference in affinity of the two drugs to brain receptors. Olanzapine affinity is related more to serotonin 5-HT2 than to dopamine-2, whereas sulpiride is considered a selective D2 blocker. The adjunction of a selective D2 antagonist to olanzapine may act as the olanzapine's augmentor by enhancing D2 blockage. This mode of treatment was introduced to six patients with chronic schizophrenia who showed noteworthy and rapid clinical improvement, supported by a decrease in their scores on the Positive and Negative Syndrome Scale and Brief Psychiatric Rating Scale. No bothersome side effects were noticed. This clinical approach is in accordance with the findings of previous reports assessing the efficacy of the combined treatment of clozapine and sulpiride. The grounds for this treatment regimen using olanzapine rather than clozapine are discussed, calling for further studies to affirm the hypothesis and clinical results.