Moclobemide. An update of its pharmacological properties and therapeutic use

Unlike older monoamine oxidase inhibitors, which irreversibly and nonselectively bind monoamine oxidase (MAO), moclobemide is a reversible and selective inhibitor of the MAO-A isozyme. Moclobemide only weakly potentiates the pressor response induced by tyramine or other indirectly acting sympathomimetics; therefore, there is no need to avoid dietary tyramine or over-the-counter decongestants with moclobemide as there is with older MAO inhibitors. Recent clinical trials and meta-analyses have confirmed the efficacy of moclobemide in the treatment of depressive disorders. Moclobemide has been shown to have similar efficacy to tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs) and nonselective, irreversible MAO inhibitors. Long term follow-up studies of 6 to 12 months' duration have demonstrated that the antidepressant efficacy of moclobemide is maintained. Moclobemide, given alone or in combination with another antidepressant, has shown some efficacy in patients with refractory depression; however, comparative trials are required to confirm these findings. Data are also available to show clinical efficacy of moclobemide in the management of social phobia. Comparative studies have established that moclobemide is better tolerated at therapeutic dosages and has less toxicity in overdose than TCAs and nonselective, irreversible MAO inhibitors. Moclobemide lacks the anticholinergic, sedative and cardiovascular effects associated with many of the older antidepressants. Compared with SSRIs, moclobemide has a similar overall tolerability, although it tends to cause fewer gastrointestinal effects than the SSRIs and has not been reported to interfere with sexual function. In summary, recent data which confirm and extend its comparative therapeutic efficacy and low potential for adverse effects have established moclobemide as an effective treatment in depressive disorders. The drug is also effective in patients with a primary diagnosis of social phobia. Its lack of adverse anticholinergic, cardiovascular, cognitive and psychomotor effects makes moclobemide a particularly useful option in the elderly or patients with cardiac disease.     

Type 2 diabetes: new therapeutic perspectives

UKPDS: The results of the United Kingdom Prospective Diabetes Study (UKPDS) were reported in 1998. This multi-center, prospective, randomized, intervention trial of 5102 newly-diagnosed patients with type 2 diabetes mellitus was aimed at determining whether improved blood glucose control can prevent complications and reduce associated morbidity and mortality. THE RESULTS: Improved blood glucose control was shown to reduce the number of complications, mainly by reducing the effect of microangiopathy. There was however no reduction in the number of diabetes-related deaths nor in the risk of myocardial infarction or sudden death. CONTROVERSY OVER CALCIUM ANTAGONISTS: Calcium antagonists are suspected of increasing the risk of cardiovascular disease. On the basis of published reports, the JNC VI guidelines are recommended: calcium antagonists should not be used as first line treatment in diabetics. RECENT DRUGS: Acarbose, an alpha-glucosidase inhibitor, lowers post-prandial blood glucose level. It has marketing approval for single-drug regimens in France. Miglitol, another alpha-glucosidase inhibitor, would have the same therapeutic effect. Orliatort, an gastro-intestinal lipase inhibitor, is indicated in obese patients but long-term results are lacking to evaluate effects in diabetics.     

Efficacy and safety of fluorescein angiography with orally administered sodium fluorescein

OBJECTIVE: To investigate the clinical effects on detrusor overactivity of a new method of transcutaneous reciprocal electrical stimulation of the thigh muscles. PATIENTS AND METHODS: Nineteen patients with detrusor overactivity, comprising 14 with detrusor hyperreflexia (DH) and five with idiopathic detrusor instability (IDI), were studied. Electrical stimulation was applied alternately to the quadriceps and hamstring muscles of one or both legs through surface electrodes for 20 min. The treatment was given once a day for 14 days and then the patients were evaluated urodynamically. RESULTS: All 19 patients tolerated the therapy well and none reported any adverse effects. The mean maximum cystometric capacity increased significantly (P < 0.05) after treatment. In 11 of the 19 patients, the maximum cystometric capacity was increased by > 50% of the pretreatment value; this occurred in eight of 14 of those with DH and in three of five of those with IDI. In six of the 11 who responded in this way, there was a clinical improvement in their urinary incontinence and frequency for several weeks to 3 months after the period of therapy. A second 14-day treatment was also effective in all four patients who underwent a repeat trial. CONCLUSION: This method of transcutaneous electrical stimulation can inhibit DH as well as IDI with no adverse effects. The suppressive effect on detrusor overactivity may persist for several months and repeat trials appear to be effective. Thus, we believe that this new stimulation technique should be tried as an alternative to other types of electrical stimulation and augmentation cystoplasty.     

Cough induced by quinapril with resolution after changing to fosinopril

OBJECTIVE: To report a case of chronic, nonproductive cough secondary to the angiotensin-converting enzyme (ACE) inhibitor quinapril, with complete resolution after switching to another ACE inhibitor, fosinopril. DATA SOURCES: All relevant articles from January 1985 through February 1993 were identified, primarily through MEDLINE search and review of pertinent articles' bibliographies. CASE SUMMARY: A 68-year-old woman developed a dry, irritating cough within one month of starting quinapril therapy for the treatment of essential hypertension. The patient was a nonsmoker with no respiratory illnesses. The cough continued for the duration of therapy with quinapril. One month after changing to fosinopril therapy, the patient reported complete resolution of the cough. She remains cough-free to date. DISCUSSION: Cough induced by ACE inhibitors is a frequently documented adverse effect. It is severe enough to require discontinuation of therapy in 1-10 percent of patients. The cough is considered to be a class-related adverse effect with cross-reactions between ACE inhibitors routinely reported. At this time, changing to another ACE inhibitor or additive therapy with nonsteroidal antiinflammatory drugs is not recommended. Discontinuation of the ACE inhibitor results in rapid alleviation of the cough, although this is not always necessary, as most patients may experience a cessation or decrease in cough. We report a case of cough following the administration of quinapril, with complete resolution after changing to the alternative ACE inhibitor fosinopril in a patient with essential hypertension. CONCLUSIONS: Cough has been encountered commonly after the administration of ACE inhibitors. Frequency of cough is variable and although this complication has been described as a class effect, patients with a persistent, severe ACE inhibitor-induced cough may benefit from a trial of fosinopril therapy. This may be particularly useful in patients unable to tolerate an alternative class of antihypertensive agents.     

Aconitine poisoning following the ingestion of Chinese herbal medicines: a report of eight cases

BACKGROUND: Traditional Chinese medicines often contain 'chuanwu' and 'caowu', the roots of certain Aconitum species which are thought to have an anti-inflammatory effect in many conditions. Excessive amounts of these materials, which contain diterpene alkaloids particularly aconitine, can produce toxic effects and occasional fatalities. AIMS: This study was conducted to document the adverse effects related to these herbal medicines which resulted in hospital admission and to determine the outcome in these patients. METHODS: A retrospective survey was conducted of patients admitted to the Prince of Wales Hospital, Hong Kong with suspected adverse effects from Chinese herbal medicines containing chuanwu or caowu over a two year period from 1989 to 1991. RESULTS: Eight patients were identified with features of mild to moderate intoxication including nausea and vomiting, paraesthesiae or numbness in the mouth and extremities, hypotension and ventricular extrasystoles. The management of aconitine poisoning is essentially supportive and in-hospital observation with ECG monitoring should be continued for at least 24 hours because of the risk of cardiovascular collapse and ventricular arrhythmias. The medical profession and general public should be alerted to the potential toxicity of these herbs and their usage should be controlled by legislation in Hong Kong as it is in some other countries.     

Experience with two types of electromyography monitoring electrodes during thyroid surgery

The cardiac adverse effects of interferon (INF) treatment have been reported recently in various clinical trials of INF. In this study, the cardiac effects of recombinant INF-alpha treatment were evaluated prospectively in a group of patients with chronic active viral hepatitis (CAH). Sixteen patients with CAH type B, 14 patients with CAH type C and one patients with CAH type D were included in this study, and 4.5, 3 and 9 MU of recombinant INF-alpha-2a was administrated three times a week to these patients, respectively. The durations of treatment were 6 months for CAH type B and C, and 12 months for type D. The cardiac status of all patients was evaluated and monitored with a detailed medical history, physical examination, electrocardiography (ECG), telecardiography, echocardiography and heart rate variability tests at the beginning of the study and at the first and sixth months of INF therapy and also 6 months after ceasing the therapy. The clinical evaluation of patients before the treatment revealed that three had hypertension, one had a past medical history of myocardial infarction, one had a prosthetic mitral valve replacement and another had left hemiblock in her ECG record. No significant changes and adverse effects were detected in clinical examination and cardiovascular tests of all patients, either in pre-existing cardiovascular diseases, during therapy and after stopping the treatment. The cardiac adverse effects of INF reported in previous studies are questionable and we conclude that it can be used safely in CAH patients. Therefore, it should be kept in mind that fever and tachycardia may occur during the first and second weeks of INF therapy and patients with high risk for cardiac disease should be monitored closely in this period of treatment.     

Pathology of MEN-1: morphology, clinicopathologic correlations and tumour development

Augmentation therapy is used for those situations where a patient's depression is either treatment-resistant, or partially and/or insufficiently responsive to treatment. It also may be used to attempt to induce a more rapid treatment response. Using drugs together may increase the risk of adverse effects, through potentiation of existing adverse effects or alterations in plasma concentrations of the drug. It is important that clinicians are aware of potential risks of augmentation therapy. Lithium augmentation of a tricyclic antidepressant is relatively well tolerated and the dangers are no greater than using these medications on their own. There are also no reports of serious adverse events when lithium is added to a monoamine oxidase inhibitor. With lithium augmentation of selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitor (SSRI) therapy there have been case reports of the development of a central serotonin syndrome, and thus caution must exercised. A serious concern when using a tricyclic antidepressant to augment an SSRI is the effect of the SSRI on the cytochrome P450 system and the resulting significant increase in tricyclic antidepressant blood concentrations. Augmentation with thyroid hormones appears to be well tolerated and effective. Case reports and open studies indicate that augmentation with buspirone and the psychostimulants, carbamazepine and valproic acid (valproate sodium) is effective and results in minimal adverse effects. However, there is no empirical evidence supporting these results. Recent work supports the tolerability and efficacy of pindolol augmentation. Considerable caution should be exercised when combining psychotropic drugs. The practitioner should only do so with a full knowledge of the compounds involved and their pharmacological properties.     

Laparoscopic appendectomy in the adult

AIM OF THE STUDY: The benefits of laparoscopic appendectomy remain controversial. The aim of the study was to evaluate the advantages and disadvantages of this technique. MATERIAL AND METHODS: Four hundred and forty-eight patients operated on for suspected appendicitis during a 5-year period were analysed in a retrospective study. The preoperative diagnosis was corrected in 21.4% of the cases (8.1% for males and 28.7% for females) and the conversion rate was 9.7%. There were 17 patients with generalized peritonitis and 28 with localized peritonitis. During the past year, this surgical method was introduced in another hospital and a prospective study included 92 consecutive patients operated on for appendicitis. The operating time was 53 minutes and the conversion rate was 7.6%. There were five patients with generalized peritonitis and eight with localized peritonitis. RESULTS: There were no postoperative deaths. In the first period, the morbidity rate was 2.3% in the laparoscopic group without conversion. After pathological examination, there was a 14.2% rate of normal appendix. The mean hospital stay was 4.3 days. In the second period, there were only three minor complications and the mean hospital stay was 4.19 days. CONCLUSION: The choice of laparoscopic approach is associated with some advantages: corrections of the diagnosis (mainly in young women) and simplification of the postoperative course, provided that the surgeon has sufficient experience.     

Adverse events after endoluminal repair of abdominal aortic aneurysms: a comparison during two successive periods of time

PURPOSE: The aim of this study was to document the incidence rate of adverse events after endoluminal repair of abdominal aortic aneurysms (AAAs) during two successive periods of time. METHODS: One hundred ninety patients (175 men, 15 women; mean age, 72 years) underwent endoluminal repair of AAAs in a 5(1/2)-year period. Adverse events were documented prospectively for all the patients throughout this interval. An adverse event was defined as any of the following events: a death within 30 days, a conversion to open repair, the need for further intervention (either open or endovascular), the need for hemodialysis, a failure to cure the AAA, and wound complications. The patients were divided into two groups those who underwent operation in the initial 3-year period (group I; n = 75) and those who underwent operation in the subsequent 2(1/2)-year period (group II; n = 115). The results were analyzed for total adverse events for both periods of time and for difference in incidence rates within categories of adverse events between the two groups. RESULTS: Eight patients (4.2%) died in the perioperative period. The endoluminal repair failed in 17 patients (8.9%), which necessitated a primary conversion to open repair at the original operation. In 88 patients, 110 adverse events occurred. There was no significant difference in the incidence rates of adverse events in patients in group I (37/75) and group II (51/115). Apart from primary conversion (P =.007), there was no significant difference in the incidence rates of adverse events between group I and group II within the following categories: perioperative (within 30 days) deaths, primary conversion, secondary conversion, supplementary endoluminal repair, intervention for lower limb ischemia, hemodialysis necessitated, failure to cure the AAA as a result of persistent endoleak, and wound complications. CONCLUSION: Despite improvements in technology and increasing experience, adverse events continue to occur in a relatively high proportion of patients (45%) who undergo endoluminal repair of AAA. Reporting the incidence rates of adverse events provides a more accurate picture of the morbidity rates of the endoluminal method rather than simply listing the procedures as successes or failures. The similarity in the incidence rates of adverse events in patients in group I and group II suggests that there are inherent risks in the endoluminal method rather than iatrogenic complications that occur during the learning curve with a new technique.     

Risk-benefit assessment of newer versus older monoamine oxidase (MAO) inhibitors

The first generation of monoamine oxidase (MAO) inhibitors fell into disuse because of poor efficacy in major depression with melancholia and/or endogenous depression, and because of poor tolerability (drug interactions and the 'cheese' effect). New MAO inhibitors, reversible inhibitors of MAO-A (RIMAs), are able to induce a reversible and specific inhibition of MAO-A. Consequently, the inhibition of MAO is quicker and the dose-response relationship improved, such that dosage adjustment is easier. Also, no carry-over effect once treatment is terminated is observed. The frequency and severity of drug interactions with RIMAs is reduced, although coadministration with pethidine (meperidine) or dextromethorphan should still be avoided. No specific subgroup of patients with depression has shown a better or worse response to RIMAs. The presence of melancholia in major depression, or the existence of endogenous depression, are not predictive of reduced efficacy compared with tricyclic antidepressant (TCA) reference compounds. Dysthymic patients have shown a good response to both RIMAs and TCAs independent of the co-existence of a major depressive episode. Older MAO inhibitors are more effective than TCAs in the treatment of atypical depression, and further studies are needed to confirm if this is true for RIMAs. Long term studies to evaluate the effects of RIMAs on disease recurrence are also required. RIMAs are better tolerated than older MAO inhibitors, including use in subgroups particularly at risk of adverse effects such as the elderly. Overall, RIMAs appear to represent therapeutic progress in the treatment of depression in terms of both efficacy and tolerability.     

Epidemiology and treatment of post-stroke depression

Depression is a common and serious complication after stroke. According to epidemiological studies, at least 30% of stroke patients experience depression, both early and late after stroke. However, in clinical practice only a minority of the patients are diagnosed and even fewer are treated. There are several studies confirming the magnitude of the problem but the main conclusion which can be drawn from the few treatment studies published is that tricyclic antidepressants cannot be recommended for the treatment of post-stroke depression, mainly because of the high frequency of contraindications and adverse effects. Until now there has only been 1 double-blind, placebo-controlled treatment study from which some general conclusions can be drawn. The study evaluated a selective serotonin reuptake inhibitor (citalopram) and concluded that the drug was well tolerated and effective for the treatment of post-stroke depression. However, when treatment was initiated very early, both the treatment group and the placebo group improved equally during the first 7 weeks after stroke. This finding could indicate diagnosis difficulties during the first few weeks after stroke. A recent study, although small, comparing the combination of drugs with either noradrenergic (desipramine plus mianserin) or noradrenergic and serotonergic effects (imipramine plus mianserin) for post-stroke depression, indicated that drugs with the dual effect may be more effective. Many more double-blind placebo-controlled treatment studies and studies comparing the efficacy and adverse effects of various antidepressants in patients with post-stroke depression need to be conducted. According to 3 small studies, electroconvulsive therapy (ECT) seems to be quite well tolerated and therefore ECT may also be considered in the treatment of post-stroke depression. Future studies should also address the long term efficacy of treatment for post-stroke depression.     

Gallstone disease in patients over the age of 80. Surgery or long-term medical treatment?

OBJECTIVE: Growth in the geriatric population is increasing the biliary pathology of the elderly, thus becoming more frequent in the medical environment. The different therapeutic methods that are at present in use, should be applied to this group, employing open cholecystectomy as a reference. MATERIAL AND METHODS: During a period of 5 years we have attended 209 patients over the age of 80 (13.8 of the total of gallstones), 76 patients (36.4%) underwent surgery and in 133 cases (63.6%) another therapeutic method was decided upon. The progression, complications and mortality rate are studied closely herein. RESULTS: The majority, 156 (74.6%) were not previous admissions and in 108 (51.7%) the symptoms had been present for less than one month. Eighty four (40.2%) were suffering from jaundice on admission (on average 4 days) and 89 (42.6%) showed signs of inflammation. 23 patients (11%) were submitted only to an endoscopic sphincterotomy. Of those patients who underwent surgery, 52 (67.5%) had a range of inflammatory phenomena. Open cholecystectomy was carried out on 65 patients (85.5%). Sixty one patients (29.2%) presented complications, 38 (50%) in the group underwent surgery. Twenty eight patients (13.4%) died-9 (11.8%) of the 76 patients were operated upon. CONCLUSIONS: Elderly patients can undergo surgery in selected cases with an acceptable mortality rate and high morbidity. Surgery is recommended in those of a lesser age, not always possible as many of them lacked prior symptoms.     

A review of protease inhibitor-induced hyperglycemia

Hyperglycemia is an adverse effect that occurs with all protease inhibitors, although few cases have been reported in the literature. Most patients with human immunodeficiency virus infection receiving antiretroviral therapy are also taking at least one protease inhibitor. Patients with a family history of diabetes mellitus may be at a greater risk of developing this adverse effect. It is therefore prudent to monitor all patients starting protease inhibitor therapy for the onset of diabetes or hyperglycemia, particularly those with a family history of diabetes. Baseline fasting plasma glucose or serum glucose level should be measured with follow-up measurements every 3 months for approximately 6-12 months.     

Correlation of waiting time with adverse events in patients admitted for nonelective permanent pacemaker implantation

OBJECTIVE: To determine the effect of a dedicated permanent pacemaker implantation procedure room on waiting time and waiting time-related morbidity. DESIGN: Retrospective chart review. SETTING: Two tertiary care teaching hospitals in southern Ontario; one with a dedicated procedure room (centre B) and one without (centre A). PATIENTS: Two hundred and fourteen consecutive patients who required permanent pacing urgently or emergently. METHODS: Charts were examined retrospectively at centre A (131 patients) and centre B (83 patients) to determine the waiting time for and the number of preoperative adverse events in nonelective permanent pacemaker implantation. RESULTS: Patients in centre A waited a mean of 4.5 +/- 3.0 days while patients in centre B waited a mean of 1.9 +/- 1.6 days (P = 0.0001). Centre A patients experienced a total of 57 adverse events that were likely or possibly related to the waiting period, while patients at centre B experienced eight such events (P < 0.0001). Thirty-three per cent of the centre A patients experienced at least one adverse event, while 8% of centre B patients experienced at least one adverse event (P < 0.00001). Of the centre A patients who waited for more than six days (26 patients), 58% had at least one adverse event, compared with 26% of those who waited less than six days (105 patients, P = 0.0009). CONCLUSIONS: Delays in implanting nonelective permanent pacemakers are strongly associated with an increase in adverse events. Measures to shorten the waiting time are likely to result in a reduction in morbidity in conjunction with a beneficial impact on health care resource utilization.     

Effects of monoamine oxidase inhibitors on the acid metabolites of some trace amines and of dopamine in the rat striatum

The effects of the administration of selective and non-selective inhibitors of monoamine oxidase (MAO) on the concentrations of three trace acid metabolites [phenylacetic acid (PAA); m-hydroxyphenylacetic acid (mHPAA); and p-hydroxyphenylacetic acid (pHPAA)] and of an acid metabolite of dopamine [3,4-dihydroxyphenylacetic acid (DOPAC)] in the rat striatum were determined. Administration of brofaromine (1-100 mg/kg, s.c.) a type AMAO inhibitor, dose-dependently decreased DOPAC and mHPAA levels. pHPAA levels were decreased by 100 mg/kg brofaromine, but PAA levels were unaffected. Doses of deprenyl of less than 100 mg/kg, i.p., had no effect on any of the acids, while 100 mg/kg decreased DOPAC, mHPAA and pHPAA but not PAA levels. Clorgyline, pargyline and tranylcypromine treatment decreased the levels of DOPAC, mHPAA and pHPAA but not PAA. Administration of alpha-monofluoromethyldopa, an inhibitor of aromatic amino acid decarboxylase, decreased the levels of all four acids. It was concluded that deamination of the respective parent amine by type A MAO is primarily responsible for the synthesis of DOPAC and mHPAA, but that another pathway contributes to pHPAA synthesis. It appears that either PAA arises predominantly independently from the actions of MAO or that is removal via transport or further metabolism regulates its concentration.     

Principles of acute treatment of Horton's disease. Role of high-dose corticosteroid therapy

Corticosteroid therapy, the elective treatment for temporal arteritis, can produce adverse effects on bone in this elderly population which usually occur late after acute high-dose administration. Such adverse effects are exceptional and generally have little impact as long as certain cortisone-sparing principles are followed: duration of acute treatments should be as short as possible; dosage can be tapered off rapidly, cutting the acute dose in half in 4 weeks; to titrate dosage, inflammatory proteins should be monitored (especially CRP because of its rapid kinetics and sometimes another protein with slower kinetics); this appears to be more useful for cortisone-sparing than the classical method based on clinical analysis and sedimentation rate; acute regimens should be accompanied by anticoagulation until figrinogen has returned to normal levels; clinical relapses during treatment are usually benign and can generally be controlled by raising the dose slightly; in case of failure due to an acute flare-up far from corticosteroid administration, it would be interesting to study the cortisone sparing effect of giving a 240 mg i.v. bolus of methylprednisolone followed by low-dose corticosteroids; if the relapse is only expressed in laboratory tests, holding the dose at same plateau for two weeks generally leads to spontaneous normalization. Intravenous bolus methlyprednisolone is well tolerated in this population of elderly patients. There is no recognized indication in the uncomplicated forms of temporal arteritis. The cortisone-sparing effect of this technique may result from the fact that the acute oral dose can be reduced. Complicated forms, particularly with ocular involvement, are recognized indications for bolus administration although the administration modalities have not yet been validated. In patients with overt ocular involvement, repeating emergency high-dose i.v. boluses every 6 to 8 hours warrants evaluation with the objective of recovering visual function.     

Intravenous desensitization to mechlorethamine in patients with psoriasis

Eight patients with psoriasis who had developed contact allergy to mechlorethamine hydrochloride (nitrogen mustard) were subjected to a regimen of intravenous infusion of small amounts of the drug in an attempt to produce desensitization. Although three of eight developed negative patch tests and were presumed to be desensitized, only one patient was able to use the drug therapeutically, and then only for a period of eight months, after which allergy recurred. The other two patients whose allergic contact dermatitis was abolished by the infusions were unable to use mechlorethamine therapeutically because of pruritus. Seven patients experienced some adverse reaction to the infusion. Intravenous desensitization of psoriatic patients who are allergic to mechlorethamine was not successful enough as a useful clinical procedure to allow them to once again use the drug therapeutically.     

Dural tears secondary to operations on the lumbar spine. Management and results after a two-year-minimum follow-up of eighty-eight patients

We reviewed the results of acute management of patients who had sustained a dural tear during an operation on the lumbar spine, and we attempted to determine the long-term sequelae of this complication. In the five years from July 1989 to July 1994, 641 consecutive patients had a decompression of the lumbar spine, performed by the senior one of us; of these patients, eighty-eight (14 percent) sustained a dural tear, which was repaired during the operation. The duration of follow-up ranged from two to eight years (average, 4.3 years). Postoperative management consisted of closed suction wound drainage for an average of 2.1 days and bed rest for an average of 2.9 days. Of the eighty-eight procedures that resulted in a dural tear, forty-five were revisions; these revisions were performed after an average of 2.2 previous operations on the lumbar spine, all of which resulted in a scar adherent to the dura. Only eight patients had headaches related to the spinal procedure and photophobia in the postoperative period; these symptoms resolved in all but two patients, both of whom had had a revision operation. Each of the two patients had symptoms of a persistent leak of spinal fluid and needed a reoperation for repair. Overall, seventy-six patients had a good or excellent result and twelve had a poor or satisfactory result with some residual back pain. One patient had arachnoiditis, and another had symptoms of viral meningitis one month postoperatively. A dural tear that occurs during an operation on the lumbar spine can be treated successfully with primary repair followed by bed rest. Such a tear does not appear to have any long-term deleterious effects or to increase the risk of postoperative infection, neural damage, or arachnoiditis. Closed suction wound drainage does not seem to aggravate the leak and can be used safely in the presence of a dural repair.     

Infectious diseases

Routine antenatal screening can detect some potentially serious infectious diseases or susceptibility to infection and allow intervention to prevent adverse outcomes. However, screening programmes can only be justified if appropriate criteria are met for the quality of laboratory tests and interventions. For many infections that are associated with adverse maternal or fetal effects, there are no suitable, cost-effective methods of screening or prevention. However, early diagnosis of infection in high-risk women or those with symptoms can allow preventive intervention. Acute febrile illness or other symptoms consistent with infection during pregnancy should be investigated more diligently than in a non-pregnant woman. Early diagnosis of an apparently trivial maternal infection may prevent serious fetal disease. When the diagnosis of maternal infection is made, appropriate action depends on the nature of infection and the stage of pregnancy at which it occurs. The results of serological test should be confirmed, preferably by a reference laboratory, by retesting the original specimen(s) and/or testing further specimens, as appropriate. Management decisions generally should be made in consultation with an infectious disease physician or clinical microbiologist with experience of infectious diseases in pregnancy.     

Preferential localization of monoamine oxidase type A activity in neurons of the locus coeruleus and type B activity in neurons of the dorsal raphe nucleus of the rat: a detailed enzyme histochemical study

Using enzyme histochemistry for monoamine oxidase (MAO) activity, we have examined whether MAO type A or type B or both are localized in neurons of the locus coeruleus (LC) and dorsal raphe nucleus (DR) of the rat. After pretreatment with various concentrations of the MAO type A inhibitor clorgyline or the type B inhibitor deprenyl, non-fixed frozen sections of the brain were histochemically stained for MAO activity with tyramine as a common substrate for the two types. MAO activity of the stained neuron was determined by measuring optical density of the staining. Percentage inhibition of the control MAO activity was plotted against increasing concentrations of the inhibitors. MAO activity of LC neurons was inhibited by low concentrations of clorgyline with a monophasic dose-response curve but not with a biphasic curve. Higher concentrations of deprenyl were needed to inhibit of LC neurons. MAO activity of DR neurons was inhibited by low concentrations of deprenyl with a monophasic dose-response curve. Clorgyline inhibited the MAO activity of DR neurons at only higher concentrations. When the sections without inhibitor pretreatment were incubated with the type A preferential substrate serotonin, the MAO activity was strongly stained in LC neurons but very weakly in DR neurons. With the type B preferential substrate beta-phenylethylamine, the staining was intense in DR neurons while very faint in LC neurons. These findings suggest that (i) almost all the MAO activity in LC neurons is of type A, and (ii) the MAO activity in DR neurons is predominantly of type B.