Monoaminoxidase inhibitors as a cause of serotonin syndrome : a systematic case review based on meta-analytic principles

INTRODUCTION: Serotonin syndrome (SS) is a toxic state characterized by increased serotonin activity. It has been suggested that severe serotonin syndrome usually involves monoaminoxidase inhibitors (MAOIs). OBJECTIVES: To quantify in how far severe SS is associated with MAOIs. METHODS: Systematic review and quantitative analysis of all SS cases published between 1 January 2004 and 31 December 2014. Severe SS was defined as cases, either requiring intensive care or resulting in death. Cases were included if they met the diagnostic criteria for SS according to at least one of the three diagnostic criteria systems (Hunter, Radomski and Sternbach). RESULTS: Of the 299 included cases, 118 (39%) met the definition for severe SS. Eight cases had insufficient information to enable severity classification. Of the severe cases, 48 (40%) involved a MAOI. Of these, 67% related to psychiatric MAOIs, such as phenelzine and moclobemide and 33% to a somatic MAOI, such as methylene blue and linezolid. Of the remaining 173 non-severe SS cases, 24 cases (13%) involved a MAOI. In these, 12% related to a psychiatric MAOI and 83% to a somatic MAOI. One case (4%) had a combination of both. The odds ratio for MAOI involvement in severe versus non-severe serotonin syndrome was 4.3 (CI 2.4 – 7.5; p < 0.001). CONCLUSIONS: In the majority of published case reports, drugs other than MAOIs are involved in serotonin syndrome, even in severe cases. MAOIs are, however, more common in severe serotonin syndrome than in non-severe cases. CONFLICT OF INTEREST: M. Ott: scientific advisory board member of Astra Zeneca, Sweden. U. Werneke: received funding for educational activities on behalf of Norrbotten Region; Astra Zeneca, Eli Lilly, Janssen, Novartis, Otsuka/Lundbeck, Servier, Shire, Sunovion. Others: Non

Validity of Cultures of Fluid Collected through Drainage Catheters versus Those Obtained by Direct Aspiration

To examine the validity of cultures of fluid collected through drainage catheters, we reviewed retrospectively fluid specimens that had been collected through catheters in place for at least 2 days. These specimens were taken from patients at a large tertiary-care hospital. A total of 974 specimens representing 620 patient episodes were received. For 554 (89%) episodes there was no reliable imaging evidence for localized infection, rendering the results uninterpretable. The remaining 66 (11%) episodes were followed within 2 days by radiologically guided or open aspiration of one or more fluid collections (predominantly in the abdomen or pelvis) near the drainage catheter, allowing comparison of culture results of 59 direct aspirates with those of prior catheter drainage. In 33 (56%) of these 59 cases, matched culture results were equivalent for therapeutic decision making. However, relying on results of catheter drainage cultures would have led to inadequate antimicrobial therapy in 13 (22%) cases, to excessive therapy in 11 (19%) cases, and to both in 2 cases (3%). We conclude that radiological imaging should be standard practice in the assessment of deep-tissue infections in patients with drainage catheters, and that direct aspiration of potentially infected fluid collections is the most reliable method of obtaining specimens for culture that should be used to guide therapy

A comparative study of 10-Fr vs. 7-Fr straight plastic stents in the treatment of postcholecystectomy bile leak

Background: Biliary decompression is a key factor in the treatment of postcholecystectomy bile leak. However, the optimal size of the stent introduced by therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is yet to be determined. The aim of the study was to compare the effectiveness of two straight plastic stents with different sizes (10-Fr and 7-Fr) in the treatment of postcholecystectomy bile leak. Methods: Between January 2003 and August 2006, 63 patients underwent therapeutic ERCP for postcholecystectomy bile leak. After visualization of the bile duct injury, endoscopic sphincterotomy was performed and the patients were randomized to receive either a 7-Fr (31 subjects, group A) or a 10-Fr (32 subjects, group B) straight plastic stent for four weeks. The success of the endoscopic treatment was determined by the elimination of the symptoms and the removal of the drain without any adverse outcomes. Results: The endoscopic intervention was successful in 29 patients of group A (93.54%) and in 31 patients of group B (96.87%). In the remaining two patients of group A, the 7-Fr stent was substituted by a 10-Fr stent after 7 days because the leak remained unaffected, resulting in healing of the leaks. Surgery was required in the remaining one patient of group B. Eight patients developed post-ERCP pancreatitis (5 mild, 2 moderate, 1 severe), which was treated conservatively. Conclusions: This trial suggests that the stent size does not affect the outcome of the endoscopic intervention in postcholecystectomy bile leaks due to minor biliary tract injury; however, larger cohorts are required to confirm the optimal stent size in bile leaks due to major bile duct injury