The Prophylactic Effect of Oral Olanzapine on Postoperative Nausea and Vomiting in Laparoscopic Gynecological Surgery: A Randomized Clinical Trial

BackgroundAlthough the antiemetic effect of olanzapine on chemotherapy-induced nausea and vomiting has been characterized, the prophylactic role of olanzapine on postoperative nausea and vomiting (PONV) has not been fully elucidated. This clinical trial aims to examine the effectiveness of olanzapine for preventing PONV.MethodsPatients undergoing laparoscopic gynecological surgery at 5 university hospitals in Japan will be randomly assigned to receive either 5 mg of oral olanzapine or placebo 2 hours before the induction of anesthesia. All patients will receive intravenous dexamethasone at the induction of anesthesia. The primary outcome will be the incidence of postoperative nausea and vomiting within 24 hours after surgery. Secondary endpoints will include longitudinal changes in the incidence of postoperative nausea and vomiting and overall patient satisfaction.DiscussionThis trial will provide a high quality evidence whether olanzapine prevents PONV in gynecological laparoscopy patients at a high risk for PONV.Ethics and disseminationThe trial was approved by the institutional review board of the each participating study site. Study findings will be disseminated through peer-reviewed publications and in conference presentations.Trial registrationUMIN Clinical Trials Registry (UMIN-CTR) ID: 000022634, Registered on October 1, 2016 https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000026031

A Case of Reversible Dementia Due to a Strictly Fruitarian Diet

A 49-year-old man was admitted in the Psychiatric Unit of our Hospital due to an acute episode of severe agitation and persecutory ideas forcing the wife to bring him to the Emergency Department (ED). His medical history was marked by a couple of similar accesses to the ED with acute agitation in the recent past. In addition, his wife reported in the last 2 years an inclination to retirement and depressive mood and a continuous decline in mood with apathy and inertia and deficits in episodic memory, with increasing forgetfulness despite maintaining good work functioning. Quite surprisingly, she added that the patient had started to follow a strict fruitarian diet with a highly predominant consumption of just apples. He did neither smoke nor drink alcohol. Notwithstanding, oral olanzapine (15 mg / day) was started with improvement of agitation; however, the patient showed a gradual cognitive worsening with disorientation and executive dysfunction.

In the aftermath of clozapine discontinuation: comparative effectiveness and safety of antipsychotics in patients with schizophrenia who discontinue clozapine

BackgroundAlthough clozapine is often discontinued, there is a paucity of guidelines and evidence on treatment options after clozapine discontinuation. Moreover, it is currently unknown whether reinstating clozapine in patients formerly using clozapine should be avoided.AimsTo compare the real-world effectiveness of antipsychotics after clozapine cessation.MethodFrom Finnish registry data (1995–2017), we identified 2250 patients with schizophrenia who had been using clozapine for ≥1 year before treatment cessation. The primary analysis consisted of adjusted within-individual analyses of psychiatric ward readmission owing to psychosis and treatment failure. Secondary analyses concerned between-individual mortality differences.ResultsCompared with no use of antipsychotics, risk of psychiatric ward readmission was lowest for reinitiation of clozapine (adjusted hazard ratio (aHR) 0.49; 95% CI 0.40–0.61; P < 0.0001), oral olanzapine (aHR 0.58; 95% CI 0.48–0.71; P < 0.0001) and antipsychotic polypharmacy (aHR 0.62; 95% CI 0.53–0.72; P < 0.0001). Risk of treatment failure was lowest for aripiprazole long acting injectable (aHR 0.42; 95% CI 0.27–0.65; P < 0.0001), reinitiation of clozapine (aHR 0.49; 95% CI 0.43–0.57; P < 0.0001) and oral olanzapine (aHR 0.69; 95% CI 0.61–0.77; P < 0.0001). Mortality risk was lowest for reinitiation of clozapine (aHR 0.18; 95% CI 0.09–0.36; P < 0.0001) and oral olanzapine (aHR 0.26; 95% CI 0.17–0.40; P < 0.0001).ConclusionsClozapine and olanzapine are the most effective and safest treatment options in those discontinuing clozapine for undefined reasons. Clozapine should therefore be reconsidered in patients with schizophrenia who previously discontinued this compound.

A Case of Complex Partial Seizures Presenting as Acute and Transient Psychotic Disorder

Introduction. Complex partial seizures are focal (CPS) (i.e., start in one area of the brain) and associated with impairment in consciousness. Most of them arise in the temporal region and are characterized by aura, impaired consciousness, and automatisms. CPS that arise in temporal region are most often misdiagnosed as primary psychiatric illness. Case Report. A 25-year-old male presented with fluctuations in consciousness, aggressive behaviour, hallucination, and delusions of grandeur lasting a few hours. He was diagnosed with acute and transient psychotic disorder according to ICD10 criteria and was treated with intramuscular haloperidol 10mg BID followed by oral olanzapine 10mg. Computed tomography of brain and electroencephalogram were normal. After 15 days he presented again to the outpatient department with complaints of aggressive behaviour and sensory misinterpretations. Video electroencephalogram was recommended, which was not done due to financial constraints. The diagnosis was reconsidered and he was started on oral carbamazepine due to high clinical suspicion, of complex partial seizures, in spite of lack of EEG evidence. He responded well to antiepileptic and symptom remission has maintained well. Conclusion. Patients presenting with psychosis need careful diagnostic evaluation for other possibilities.

Pellagra induced psychosis: a rare presentation

Pellagra is a nutritional deficiency disease associated with low levels of niacin (vitamin B3). Neuropsychiatric symptoms are rare and are difficult to be diagnosed by clinicians in a timely manner. A 35 years old male was brought with complaints of generalized weakness, decreased appetite and work impairment since past 4 years. Scaly and itching skin rashes have also been present since 3 months followed by hearing voices, suspiciousness and agitated behaviour since one month. On examination, he had pruritic skin rashes over hands which extended over face and neck. His diet comprised mainly of jowar and maize and had history of occasional alcohol use. With an initial diagnosis of psychosis, the patient was started on oral olanzapine. Laboratory and imaging investigations were within normal limits. Dermatology referral confirmed pellagra clinically. The patient was started on injectable multivitamins for 14 days and later shifted to oral multivitamins. Patient showed significant improvement in his skin and neuropsychiatric symptoms. Present case suggests that physicians need to remain vigilant because it is easy to overlook such patients. Pellagra has an insidious onset and psychiatric symptoms appear rare and late in the course when disease is allowed to progress.