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OBJECTIVE: To describe a patient with longstanding depression and hypothyroidism who had marked mood improvement only after triiodothyronine (T3) was added to her thyroxine (T4) replacement therapy. CASE SUMMARY: A 50-year-old white woman had a long history of depression and documented hypothyroidism since 1991. Despite treatment with T4 with dosages up to 0.3 mg/d, she continued to be depressed, have symptoms of hypothyroidism, and have a persistently elevated thyroid-stimulating hormone concentration. Addition of a low dose of T3 to her regimen resulted in significant mood improvement. DISCUSSION: The relationship between hypothyroidism and depression is well known. It is possible that this patient's long history of depression may have been a consequence of inadequately treated hypothyroidism, due either to poor patient compliance or resistance to T4. Nevertheless, her depression responded to addition of a low dose of T3 to her regimen. This case emphasizes the importance of screening depressed patients for hypothyroidism. Her clinical course also suggests that depression related to hypothyroidism may be more responsive to a regimen that includes T3 rather than to replacement with T4 alone. This is consistent with the observation that T3 is superior to T4 as adjuvant therapy in the treatment of unipolar depression. CONCLUSIONS: Depressed patients should be screened for hypothyroidism. In hypothyroid patients, depression may be more responsive to a replacement regimen that includes T3 rather than T4 alone. Therefore, inclusion of T3 in the treatment regimen may be warranted after adequate trial with T4 alone.

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S. boulardii has been investigated in Europe and the US, and preliminary reports indicate that it is safe and effective in conjunction with vancomycin or metronidazole for the treatment of CDC, predominantly in patients who develop recurrence. S. boulardii in combination with vancomycin or metronidazole has not been shown to be more effective than either of these agents alone for treatment of a first episode of CDC. In addition, S. boulardii has not been studied in immunocompromised patients who may be at risk for developing fungemia. Ultimately, large-scale clinical studies are necessary to determine whether S. boulardii should be routinely used to treat patients with recurrent CDC. S. boulardii is currently undergoing Phase III clinical trials for CDC treatment in the US. Clinicians interested in information regarding participation in current studies may contact Biocodex Inc., in Seattle, Washington.

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Performance on the Wisconsin Card Sorting Test (WCST) is widely reported to be impaired in patients with schizophrenia. It has been hypothesized that the performance deficit on the WCST in schizophrenia is related to a dysfunction of the frontal lobe, specifically the dorsolateral prefrontal cortex. This hypothesis was tested by comparing a group of patients with schizophrenia to patients with low grade right or left frontal lobe tumors and a group of patients with non-frontal high grade tumors. The results demonstrated a remarkable similarity in performance on the WCST between patients with schizophrenia and patients with right frontal lobe tumors. Patients with left frontal lobe tumors, non-frontal tumors, and normal control subjects did not show the same pattern of performance. This study provides support for frontal lobe dysfunction in the symptomatology of schizophrenia.

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OBJECTIVE: To review the literature concerning the use of benzodiazepines for treatment of alcohol withdrawal and to determine if the current literature assessment justifies the use of lorazepam as first-line therapy. DATA SOURCES: A thorough review of the literature was performed with an online database (BRS Colleague). Articles directed at the targeted issue were chosen and additional references were obtained from the bibliographies of these articles. STUDY SELECTION: Clinical trials and case reports concerning the use of chlordiazepoxide, diazepam, and lorazepam in alcohol withdrawal treatment were reviewed. DATA SYNTHESIS: Lorazepam is considered by many to be the drug of choice for alcohol withdrawal because it undergoes glucuronidation and has an intermediate half-life. These characteristics have suggested its superiority when treating elderly patients or patients with liver disease. However, some studies suggest that a drug with a longer half-life would provide smoother withdrawal. In addition, the number of patients with liver disease treated for alcohol withdrawal is unknown. These and other factors question the recommendation of lorazepam as the drug of choice. CONCLUSIONS: Well-controlled comparison studies should be performed before recommending the routine use of lorazepam for treating alcohol withdrawal syndrome.

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The appropriateness of serum digoxin concentration (SDC) orders was evaluated with respect to indication for use, sampling time, and action taken by physicians when the reported SDC was out of the normal therapeutic range; the effect of the two data-collection methods used (retrospective and concurrent audits) on the results was studied. Criteria for the appropriate use of SDCs were approved by the medical staff through the pharmacy and therapeutics committee. Patients on adult medicine services were entered into the study as daily SDC determinations were reported by the clinical laboratory. Most of the SDCs were evaluated using approved criteria by primary pharmacist clinicians who were concurrently monitoring drug therapy and participating with the treatment team. A retrospective audit of the same patients was conducted, using only chart review. A total of 134 SDCs involving 78 patients were evaluated. Concurrent-audit results indicated that 18.7% of the SDCs were ordered without an appropriate indication, 16.4% were sampled incorrectly with respect to proper timing, and 8.2% did not result in dosage adjustments when indicated. With respect to appropriate sampling time and overall use of SDCs, significantly more SDCs met the standards under concurrent audit than under retrospective audit. The retrospective chart review method of auditing may not detect as much pertinent information as is desirable.

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