Drug Treatment of Schizophrenia

(Great Britain—The Practitioner, January 1998, p. 47.) Traditional antipsychotic medications that block dopamine receptors usually induce remission within a few weeks and, at reduced maintenance dosages, these medications may control symptoms sufficiently to enable patients to be managed in the community. These drugs typically are more effective against the active manifestations of schizophrenia, such as hallucinations, delusions and abnormal behaviors, and are less effective against negative symptoms, such as emotional blunting, social withdrawal and depression. Some patients do not respond to these drugs, and others have residual symptoms. Even with good compliance, approximately 20 percent of patients relapse during treatment. Common side effects include parkinsonism, tardive dyskinesia, endocrine abnormalities, sedation and autonomic disturbances. New antipsychotic medications are being introduced that have complex actions on several different receptors and are highly effective against both negative and active symptoms. The new drugs generally cause less sedation and anticholinergic effects than traditional drugs, but each drug has its own range of efficacy and side effect profile. Combined with community support and psychologic treatments, these agents could provide highly individualized therapy.

Subarachnoid Hemorrhage

(Australia—Australian Family Physician, October 1997, p. 1145.) Approximately 80 percent of cases of nontraumatic subarachnoid hemorrhage are the result of aneurysm rupture. Arteriovenous malformations account for up to 10 percent of cases and another 10 percent result from unknown causes. Ruptured aneurysms are surgical emergencies affecting 10 to 12 adults per 100,000 population each year. Up to one half of all cases are immediately fatal. Among patients who survive, the rate of surgical mortality is approximately 5 percent. Without surgery, one quarter of patients have another hemorrhage within two weeks, and the mortality rate for subsequent hemorrhages reaches 70 percent. Following subarachnoid hemorrhage, delayed vasospasm is common, leading to cerebral ischemia. This complication may be minimized by use of fluids, supportive therapy and the calcium antagonist nimodipine. Secondary hydrocephalus, seizure disorder, neurologic deficits, neurogenic pulmonary edema and cardiac arrhythmias also are potential complications of subarachnoid hemorrhage. The risk of rupture of an incidentally discovered aneurysm has been estimated as 3 percent per year compared with the risks of preventive surgery, estimated as a mortality rate of 1 percent and a morbidity rate of 5 percent. Management decisions about unruptured aneurysms must be individualized according to patient characteristics and the size, location and shape of the lesion.

Improved NSAID Therapy for Arthritis

(Canada—Canadian Family Physician, January 1998, p. 101.) Nonsteroidal anti-inflammatory drugs (NSAIDs) act through inhibition of prostaglandins. Since a major function of prostaglandins is to protect the gastric mucosa, the NSAIDs that relieve inflammation most effectively also produce the greatest gastrointestinal damage. It is estimated that gastric or duodenal ulceration develops in up to 20 percent of patients with arthritis who use NSAIDs. Inhibition of prostaglandins in the renal system may also precipitate renal failure in susceptible patients. A new class of NSAIDs selectively blocks prostaglandins in inflammatory tissue more than it blocks the enzymes responsible for gastric and renal function. The prototype drugs of this class, etodolac and nabumetone, have shown efficacy in the treatment of arthritis, with a significantly reduced incidence of gastrointestinal complications. An alternative strategy is the combination of a traditional NSAID with misoprostol. The increased cost of these new regimens must be balanced against the reduction in potentially serious adverse effects.

Taping for Ingrown Toenails

(Canada—Canadian Family Physician, February 1998, p. 275.) Insertion of cotton pledgets is usually recommended to elevate the corner of ingrown toenails, but this can be painful and difficult to accomplish. If ingrown toenails are likely to respond to conservative therapy, elevation of the corner often can be achieved by taping. One end of the sticky tape is applied to the area of proud flesh at the edge of the ingrown nail, and the rest of the tape is twisted around the toe to gently but firmly pull the proud flesh away from the nail. This technique works particularly well when the nail has been clipped short. In addition to taping, soaking and antibiotics (if indicated) should be used. Patients also should be advised routinely on the selection of properly fitting shoes and the correct technique for trimming toenails.