A randomised trial of peri-operative positive airway pressure for postoperative delirium in patients at risk for obstructive sleep apnoea after regional anaesthesia with sedation or general anaesthesia for joint arthroplasty.

Previous pilot work has established an association between obstructive sleep apnoea and the development of acute postoperative delirium , but it remains unclear to what extent this risk factor is modifiable in the 'real world' peri-operative setting. In a single-blind randomised controlled trial, 135 elderly surgical patients at risk for obstructive sleep apnoea were randomly assigned to receive peri-operative continuous positive airway pressure (CPAP) or routine care. Of the 114 patients who completed the study, 21 (18.4%) experienced delirium. Delirium was equally common in both groups: 21% (12 of 58 subjects) in the CPAP group and 16% (9 of 56 subjects) in the routine care group (OR = 1.36 [95%CI 0.52-3.54], p = 0.53). Delirious subjects were slightly older - mean (SD) age 68.9 (10.7) vs. 64.9 (8.2), p = 0.07 - but had nearly identical pre-operative STOP-Bang scores (4.19 (1.1) versus 4.27 (1.3), p = 0.79). Subjects in the CPAP group used their devices for a median (IQR [range]) of 3 (0.25-5 [0-12]) nights pre-operatively (2.9 (0.1-4.8 [0.0-12.7]) hours per night) and 1 (0-2 [0-2]) nights postoperatively (1.4 (0.0-5.1 [0.0-11.6]) hours per night). Among the CPAP subjects, the residual pre-operative apnoea-hypopnea index had a significant effect on delirium severity (p = 0.0002). Although we confirm that apnoea is associated with postoperative delirium, we did not find that providing a short-course of auto-titrating CPAP affected its likelihood or severity. Voluntary adherence to CPAP is particularly poor during the initiation of therapy.

Munchausen syndrome.

Munchausen syndrome is a rare condition in which the patient repeatedly seeks medical care for factitious illnesses. With this self-inflicted disease, the patients characteristically travel from one hospital to another, feigning acute, usually spectacular illnesses. The patients willingly submit themselves to extensive as well as invasive diagnostic and therapeutic procedures. Munchausen syndrome is a psychiatric disorder that requires psychiatric treatment. Reconstructive surgical procedures may be required to correct the acquired deformities. The difficulty in Munchausen syndrome lies essentially in early recognition of the psychiatric syndrome. Two exceptional cases are reported, and diagnosis and treatment are presented in the light of the current literature.

[New neuroleptic drugs]. / Les nouveaux neuroleptiques.

Novel antipsychotics are still frequently referred to as atypical. Following a brief review of the significant literature, they are presented under the sole perspective of their extrapyramidal side effect profile. Thereby, answers to whether they are novel or atypical are revisited. A tentative algorithm for their prescription is proposed as well.

Characteristics of spontaneous sleep with varying NREMS Episodes in healthy men: implication for delta activity homeostasis.

STUDY OBJECTIVES: We investigated the effects of the variation in the number of NREMS episodes on human sleep, in particular on delta activity distribution. PARTICIPANTS: Forty-one medication-free healthy men without personal or family history of psychiatric disorders. INTERVENTIONS: Subjects slept four consecutive nights, the last three were analyzed. Sleep was undisturbed and uninterrupted following self-selected schedule. RESULTS: With the exception of one night out of 123, subjects slept at least four NREMS episodes with 80% presenting five or six episodes per night. Yet, only 24% slept the same number of NREMS episodes across three nights. Shorter first NREMS episode was associated with greater number of NREMS episodes, and the total number of NREMS episodes was significantly predicted by the duration of the first one. Whether subjects slept four, five or six NREMS episodes, the proportion of TST spent in REMS, total delta power, total spectral power and the rate of delta power in the first NREMS episode did not differ between subjects. In each night, the distribution of delta activity across the first four NREMS episodes was not modified by the total number of NREMS episodes. CONCLUSION: When spontaneous sleep is allowed, healthy men mostly sleep beyond the fourth NREMS episode. Based on delta activity distribution across the first four episodes, we have demonstrated that the number of NREMS episodes does not modify delta sleep homeostasis. Only duration of first NREMS episode predicts the number of NREMS episodes slept. These results suggest that sleep homeostasis and NREMS-REMS alternation may be two independent processes.

Distribution of delta activity across nonrapid eye movement sleep episodes in healthy young men.

The distribution of delta activity across successive nonrapid eye movement (NREM) sleep episodes and its night-to-night stability across three consecutive nights were investigated by studying delta power with spectral analysis in 31 healthy young men. Repeated-measures analysis of variance (ANOVA) with polynomial contrast was applied to grouped data of absolute delta power and three indexes: (1) the rate of delta power per NREM episode to its duration, 2) the standardized rate for the last NREM episode, and 3) the logarithm of the standardized rate. A significant linear decrease across NREM episodes was observed for each variable in each successive night. In addition, using night as a second within-subjects factor, no night effect was observed. Yet, the subsequent analysis of the logarithmic data yielded greater F values in all three nights' data as well as a linear function that accounted for a greater proportion of total variance than the analysis of the nonlogarithmic data. Since a linear decline for the logarithm of a variable implies an exponential distribution for that variable, we conclude that delta activity is distributed exponentially across NREM episodes, and this finding shows a remarkable night-to-night stability.

delta-9-Tetrahydrocannabinol regulates gene expression of the growth factor pleiotrophin in the forebrain.

delta-9-Tetrahydrocannabinol (THC) is a major psychoactive component of cannabis. We here studied, by quantitative in situ hybridization at the macroscopic level, the possible modulatory effects of acute THC (5 mg/kg/i.p.) on gene expression of the growth factor pleiotrophin (PTN) in the adult rat forebrain. We found, 30 min after a single injection of THC, a significant increase of PTN mRNA concentrations in the cingulate cortex (38%), fronto-parietal cortex (31%) and caudate-putamen (27%). In conclusion, this is the first report on THC regulation of growth factor gene expression in the brain.

Activation of multiple transcription factor genes by tetrahydrocannabinol in rat forebrain.

delta-9-Tetrahydrocannabinol (THC) is a major psychoactive component of cannabis. We have recently localized a receptor for THC in the forebrain and found in the caudate-putamen that its gene expression is modulated by glucocorticoids, dopamine and glutamate. Here, we report for the first time, using quantitative in situ hybridization, that acute THC (5 mg kg-1, i.p.) regulates the mRNA levels of multiple immediate early genes in the adult rat forebrain. Twenty minutes after a single THC injection, significant increases in concentration of the mRNAs for C-FOS, C-JUN and ZIF-268 were observed in the cingulate cortex (75, 45 and 37%) and for C-FOS and ZIF-268 in the fronto-parietal cortex (60 and 64%) and caudate-putamen (81 and 32%) while JUN-D mRNA levels were not changed. These transcription factor genes might mediate putative THC modulation of neurotransmitter gene expression.

Review of the cardiovascular effects of heterocyclic antidepressants.

We review the effects of heterocyclic antidepressant compounds on the cardiovascular system. It has been shown that tricyclic antidepressants (TCAs) slow intraventricular conduction, and this can be seen on a standard ECG as the increased QRS, PR, and QTc intervals. This prolonged conduction is dangerous to patients in two conditions. In overdose, delayed conduction may lead to a complete heart block or ventricular reentry arrhythmias. Either of these complications, or a combination of both, may lead to death. When treated with TCAs at therapeutic plasma levels, depressed patients with preexisting conduction disease, particularly bundle-branch block, are at higher risk to develop symptomatic A-V block than depressed patients free of conduction disorders. Clinically, the effects of TCAs on conduction does not differ significantly within the family of drugs. Who gets complications is much more a function of severity of the patient's preexisting cardiac condition. The most common cardiovascular effect of TCAs is orthostatic hypotension. Postural hypotension is more dangerous in elderly patients because it may lead to falls that cause serious physical injuries. Severe orthostatic hypotension is more likely to develop in depressed patients with left ventricular impairment and/or in patients taking other drugs like diuretics or vasodilators. Nortriptyline has been shown to cause significantly less serious postural blood pressure drops, an important difference between this drug and other TCAs. Another cardiovascular effect of TCAs is that they reduce ventricular arrhythmias. They share this property with Type 1A antiarrhythmic compounds, and a variety of Type 1 antiarrhythmics have recently been shown to increase mortality in postmyocardial infarction patients.(ABSTRACT TRUNCATED AT 250 WORDS)