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The exact mechanism of a tramadol-warfarin interaction has not been fully determined. The authors present a case study that illustrates the risks.

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Clozapine use has declined, despite its superior antipsychotic efficacy in treatment-resistant schizophrenia. Implications for clozapine underutilization include suboptimal treatment outcomes and increased hospitalizations. Many barriers preventing the use of clozapine have been described in the literature, including suboptimal knowledge and poor perceptions. The aim of this study was to assess psychiatry prescribers' perception and knowledge of clozapine. A survey was distributed to advanced practice providers, psychiatrists, and trainees (i.e. residents and fellows) at 10 medical centers within the US and Canada. The survey asked respondents about their perception of clozapine use and assessed their pharmacotherapeutic knowledge of clozapine. Two hundred eleven individual submitted completed surveys of a possible 1152; a response rate of 18.3%. There were no statistically significant differences between the advanced practice provider plus psychiatrist groups and the trainee group for most perception (eight of nine) and knowledge (eight of nine) questions. The knowledge questions with the lowest scores pertained to clozapine reinitiation and myocarditis. The majority of all respondents (144, 68.2%) felt that clozapine prescribing was a burden. Findings of this study support the need for continued clozapine education regardless of a prescriber's age/experience. Future studies to assess barriers to clozapine prescribing should extend beyond academic centers.

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Drug-induced oral ulcers are lesions of the oral mucosa accompanied by painful symptoms, such as burning mouth, metallic taste, dysgeusia, or ageusia. This report demonstrates the first documented case of drug-induced oral ulcers with the tricyclic antidepressant nortriptyline. In this case, a 49-year-old female initiated treatment for refractory neuropathy with nortriptyline. Within 2 weeks of therapy, painful, oral, bubble-like ulcers developed. Complete symptom resolution occurred approximately 1 month after discontinuation of nortriptyline. Clinicians should be cognizant of nortriptyline's ability to potentially induce oral ulcers; however, the exact mechanism for this adverse event is unknown.

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The use of complementary and alternative medicine (CAM) is gaining popularity in the Western world. Among the general public, CAM is often perceived to be associated with less stigma, fewer adverse effects, and may be more affordable. A number of patients utilize CAM for the treatment of depression; however, as there is limited scientific evidence, the safety profile of these supplements are largely unknown. In this case, a 42-year-old man developed hypomania approximately 1 week after S-adenosylmethionine (SAMe) and 5-hydroxytryptophan (5-HTP) therapy was initiated for depression. The combination of SAMe and 5-HTP can potentially induce hypomanic episodes.