Electroconvulsive therapy in a 96-year-old patient with severe aortic stenosis: a case report and review of the literature.

We report the safe administration of a course of electroconvulsive therapy (ECT) in a 96-year-old woman with severe aortic stenosis. The patient experienced a relapse of her severe depression when ECT had been withheld because of increased concerns regarding medical risk given her age and degree of aortic stenosis. Reassessment of the case confirmed severe stenosis with a valve area of 0.5 cm2 and a peak pressure gradient across the valve of 110 mm Hg. The ventricular ejection was normal at 70% however, and after a careful weighing of the risk of ECT treatment versus the risk of withholding ECT, it was decided to proceed with ECT in this case. In the event, ECT was very well tolerated by the patient, and she experienced a full remission of symptoms. She continues to receive maintenance ECT successfully at a once-per-month frequency. This case illustrates that neither age nor aortic stenosis by itself precludes ECT in the setting of severe depression. Rather, in each case, a careful weighing of the risks both of proceeding with and withholding ECT is warranted.

Unexpected reduction in migraine and psychogenic headaches following rTMS treatment for major depression: a report of two cases.

Our objective is to report a coincident reduction in headache pain in patients treated with repetitive transcranial magnetic stimulation (rTMS) for major depressive disorder (MDD). Two patients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of MDD, non-responsive to prior antidepressant treatment who were enrolled in a sham-controlled, double-blind study of rTMS for MDD. After the study, it was revealed that both were in the active-treatment arm. Both patients suffered from near daily headaches and kept logs of headache frequency and severity before, during, and after the study. Headache pain was significantly reduced under double-blind conditions with rTMS treatment, but returned to baseline following cessation of rTMS treatment. Ultimately, when receiving rTMS post-study as a maintenance intervention for MDD (approximately 2 rTMS sessions/week), the positive effects on headache amelioration were sustained. Headache pain is frequently comorbid with mood disorders and has been reported as the most common side effect with rTMS. In these subjects, rTMS was, in fact, associated with relief of depressive symptoms and preexisting headache pain. This indicates that rTMS may be beneficial for both disorders in some patients.

Restricción en pacientes agitados atendidos en unidades de cuidado médico primario / Restriction in agitated patients attendend in units of primary medical care

El manejo inicial de pacientes agresivos es frecuente en la práctica clínica, sin embargo, tanto el diagnóstico como el tratamiento iniciales tienden a ser imprecisos. La restricción física es una práctica muy usada por el personal de la salud, pero poco se sabe sobre su metodología, indicaciones, contraindicaciones y efectos adversos. Con el interés de aportar pautas, al personal de salud, encargado de la atención médica primaria de los pacientes agresivos en Colombia; realizamos una búsqueda en la literatura de los últimos cinco años en MEDLINE, HINARI, PROQUEST y OVID mediante combinación de la siguientes palabras clave: restraint, physical, aggression; emergency services, psychiatric; tranquilizing agents, con especial atención a los artículos de revisión y metaanálisis. Se seleccionaron 28 de 202 artículos de mayor relevancia para su aplicación en nuestro medio. Las indicaciones más importantes de restricción son: el riesgo de hetero o auto agresividad y el daño a la planta física. Existen claras contraindicaciones e implicaciones éticas, médicas y legales de los procedimientos de restricción que se deben acatar juiciosamente para realizar una adecuada práctica clínica. El adecuado uso de la restricción física del paciente agitado o agresivo, en unidades de atención primaria, es vital para su adecuado tratamiento y pronóstico. Es muy importante identificar la patología médica general subyacente