This review article argues against trusting standard clozapine references, including the US package insert, because they do not include advances in the sciences of pharmacokinetics and pharmacovigilance and ignore the effects of ethnic ancestry on therapeutic dosing. The minimum therapeutic dose leading to the minimum therapeutic concentration of 350 ng/mL in serum/plasma can be used to compare individuals/groups with treatment-resistant schizophrenia. The US clozapine package insert recommends targeting doses of 300–450 mg/day and, subsequently, increments of up to 100 mg with a maximum dose of 900 mg/day. Ethnic ancestry is defined by DNA ancestry group. Asians (people with ancestry ranging from Pakistan to Japan) and Indigenous Americans are similar in clozapine dosing; their average clozapine minimum therapeutic dose ranged from 166 mg/day (female non-smokers) to 270 mg/day (male smokers). For those with European ancestry, average clozapine minimum therapeutic doses ranged from 236 mg/day (female non-smokers) to 368 mg/day (male smokers). Based on limited studies, Black (African sub-Saharan ancestry) patients may be treated with typical US doses (300–600 mg/day), assuming no poor metabolism (PM) status. Ancestry’s impact on clozapine lethality in four countries is discussed (two countries with highly homogenous populations, Denmark and Japan, and two countries with increasingly heterogenous populations due to immigration, Australia and the UK). An international guideline with 104 authors from 50 countries/regions was recently published, providing 6 personalized clozapine titration schedules for adult inpatients (3 ancestry groups and PMon-PM schedules) and recommending c-reactive protein monitoring at baseline and weekly for 4 weeks.

During the development of the DSM-5, even the lay press questioned psychiatr's scientific validity. This review provides 21st century psychiatry residents with ways of answering these attacks by defining the concepts and history of psychiatry (a branch of medicine), medicine and science. Psychiatric language has two levels: first, describing symptoms and signs (19th century descriptive psychopathology developed in France and Germany), and second, describing disorders (psychiatric nosology was developed in the early 20th century by Kraepelin and resuscitated by the US neo-Kraepelinian revolution leading to the DSM-III). Science is a complex trial-and-error historical process that can be threatened by those who believe too much in it and disregard its limitations. The most important psychiatric advances, electroconvulsive therapy and major psychopharmacological agents, were discovered by "chance", not by scientific planning. Jaspers's General Psychopathology is a complex 100-year-old book that describes: 1) psychiatric disorders as heterogeneous and 2) psychiatry as a hybrid scientific discipline requiring a combination of understanding (a social science method) and explanation (a natural science method). In the 21st century Berrios reminds us of psychiatry's unfortunate methodological issues due to hybrid symptoms and disorders, some of which are better understood as problems in communication between interacting human beings; in those situations neuroscience methods such as brain imaging make no sense. A new language is needed in psychiatry. East Asian psychiatry residents, who are not particularly attached to the antiquated language currently used, may be particularly equipped for the task of recreating psychiatric language using 21st century knowledge.
Asia ; Asian Continental Ancestry Group ; Diagnostic and Statistical Manual of Mental Disorders ; Electroconvulsive Therapy ; Europe ; Far East ; France ; History ; History, 19th Century ; History, 20th Century ; History, 21st Century ; Humans ; Mental Disorders ; Methods ; Natural Science Disciplines ; Neuroimaging ; Neurosciences ; Psychiatry* ; Psychopathology ; Social Sciences ; United States

Objective: This study aims to determine the disease-free survival and overall survival outcome of patients with IB to IIA cervical cancer managed with surgery, chemoradiation, or a combination of both in a tertiary government training hospital. Methodology: This is a retrospective study of patients diagnosed with stage IB-IIA2 cervical cancer from January 2013 to June 2017. Data were encoded using Microsoft Excel. Statistical analyses were computed using SPSS. Cox regression and Kaplan Meier analyses were used to predict survival outcomes. Results: Out of 135 patients were included in the study, 111 received treatment. 61 had no evidence of disease. Median age is 46 years with stage IB1 disease. Majority of patients underwent surgery followed by adjuvant therapy. Tumor recurrence was highest in the surgery alone group, with median time to recurrence of 19 months. Median follow-up time was 10 months. Overall 5-year survival is 51.4%; 5-year disease-free survival is 54.8%. Conclusions Age is a statistically significant factor in survival. Surgery with adjuvant chemotherapy + radiation had the most favorable survival outcome. Neoadjuvant treatment gave the least number of recurrences. Despite a small sample size, this study provides baseline data into the survival outcome of patients with locally advanced cervical cancer in our institution given the different treatment recommendations.
Uterine Cervical Neoplasms ; Disease-Free Survival ; Hysterectomy ; Chemotherapy, Adjuvant ; Neoadjuvant Therapy

We presented three patients with trochanteric tuberculosis and described the clinical and imaging findings of the infection. Histology revealed a necrotizing granulomatous bursitis and microbiology confirmed tuberculosis. All cases were successfully treated with bursectomy and curettage of the trochanteric lesion and antituberculous chemotherapy including isoniazid, pyrazinamide, rifampicin, and ethambutol.
Aged, 80 and over ; Antitubercular Agents/*therapeutic use ; *Bursitis/diagnostic imaging/pathology/therapy ; *Curettage ; Female ; *Femur/diagnostic imaging/pathology/surgery ; Humans ; Middle Aged ; *Tuberculosis, Osteoarticular/diagnostic imaging/pathology/therapy

In this report, we present a rare case of solid silicone implant displacement to the contralateral side after aesthetic gluteal augmentation, a phenomenon that has never been reported before in the literature. A 29-year-old woman with a history of gluteal augmentation 9 months previously and soft tissue infection presented for a consultation due to 3 days of sudden progressive pain in the right gluteus with erythema and edema, without a history of trauma. Displacement of the left gluteal implant to the right gluteal pocket was shown by magnetic resonance imaging. Because the patient refused implant removal, the decision was made to perform capsulotomy, to reconstruct the gluteal pockets, and to preserve the implants. The patient showed a satisfactory early and late postoperative course. Possible causes of this complication include poor surgical technique, with insufficient tissue preservation to keep the pockets apart, and the presence of seroma or hematoma that favored an infectious process, thereby leading to deterioration of the dissected soft tissues with dehiscence of the wound favoring the displacement of the implant.

Background & Objective: Currentlythere is limitedintervention for acute ischemic stroke. Recombinant tissue plasminogen activator (rTPA) has been approved for immediate recanalization after a steno-occlusive lesion of cerebral vessels. rTPA has shown its efficacy and safety from several clinical trials. The present study reports our experience with intravenous rTPA from several centers in the Philippines.Method:This is a retrospective cohort study consisting of 157 patients who qualified to receive rTPA following the NINDS trial inclusion and exclusion criteria. The primary outcome is in-hospital and 3-months mortality. Other outcome measures were determined: intracranial hemorrhage secondary to hemorrhagic conversion and functional outcome as measured by modified Rankin Scale. Additionally, standard dose (0.9mg/kg) was compared to low dose (0.6mg/kg) of rTPA in terms of mortality, intracranial bleeding and functional outcome.Results:The in-hospital mortality was seen in 23 (14.6%) and total death within 3 months was 18.3%. Independent patient (mRS 0-2) was seen in 69 (51.1%) at discharge and 95 (73.1%) at 3 months. Intracranial bleeding due to asymptomatic hemorrhagic transformation occurred in 39 (24.8%) and symptomatic hemorrhagic transformation was seen in 19 (12.1%).Conclusion: Comparing our results with SITS-MOST and Cochrane collaborations, our data showed that we have more independent patients however death and intracranial bleeding was noted to be high in our cohort of patients. Additionally, the study showed more independent patients in the low dose group.

OBJECTIVE: Glaucomatous optic neuropathy (GON), defined as definitive damage to the optic-nerve head (ONH) and retinal-nerve-fiber layer (RNFL), involves structural changes in the ONH and RNFL and functional losses in the central visual field. Due to the unique anatomic distribution of the nerve fibers as they enter the ONH, there are specific changes in the ONH correlated with specific findings in the visual-field characteristic of GON. The evaluation of these changes is discussed. METHODS: There are qualitative and quantitative methods in the structural examination of the ONH and RNFL, and quantitative techniques in the functional assessment of the central visual field. They are correlated to one another their strengths and limitations are discussed. RESULTS: Clinical evaluation of the ONH and RNFL consists of five basic rules: (1) identify the limits of the optic disc and determine its size, (2) identify the s of the neuroretinal rim, (3) examine the RNFL, (4) examine the region for parapapillary atrophy, and (5) look for retinal and optic-disc hemorrhages. These steps are simple to use and comprise a portion of the comprehensive eye evaluation. Without proper documentation of the changes in glaucoma progression may be missed. Computer-based digital-imaging technology exemplified by the HRT II, GDx, OCT, provides fast, reproducible, objective measurements of the ONH and RNFL, allowing for more precise diagnosis and monitoring of glaucoma. These changes have good correlation to functional assessments exemplified by the standard automated perimetry (SAP) and the selective perimetry (FDT, SWAP). Typical glaucomatous visu field defects include nasal step, paracentral scotoma, and arcuate defects which follow the RNFL pattern. Progression of these defects is monitored over time and needs to be differentiated from long-term fluctuation. CONCLUSION: The clinician should perform both structural and functional assessments to diagnose and monitor glaucoma. Both examinations provide complimentary information and each has its own place in the clinical care of glaucoma patients. The newer imaging devices and selective perimetry augment the diagnostic armamentarium of the clinician and should, therefore, be used appropriately.
GLAUCOMA ; OPTIC NERVE ; VISUAL FIELDS ; VISUAL FIELD TESTS ; OPTIC DISK

BACKGROUND: Non-syndromic craniosynostosis causes craniofacial asymmetry and may persist after cranioplasty. These postoperative asymmetries are primarily depressions. In some cases, patients may be subjected to pranks and harassment by their peers, affecting their psychosocial development. We propose lipoinjection enriched with adipose stem cells (ASCs) to treat the sequelae of craniosynostosis in the fronto-orbital and temporal complex in cranioplasty patients, with the goal of improving the appearance of the upper third of the face. METHODS: Twelve children (four boys and eight girls) between 4 and 8 years of age (mean age, 6 years) in the postoperative period after treatment for plagiocephaly, brachycephaly, and trigonocephaly were included, with a follow-up period of 1 to 18 months. Fat tissue was obtained from the lower abdomen, and ASCs were isolated using the Yoshimura technique. Lipoinjection was performed using several mini-approaches to ensure adequate distribution. RESULTS: Two different scales were used to evaluate the aesthetic outcomes. At 6 months, three plastic surgeons independent of the study classified the results using a Likert scale. The patients’ parents categorized the results using a visual analog scale at 6, 9, and 18 months. R esults were favorable on both scales, as the patients’ facial appearance improved and they reported increased happiness and self-esteem due to their remodeled facial appearance. CONCLUSIONS: We suggest that lipoinjection enriched with ASCs is a good alternative for correcting asymmetry of the fronto-orbital and temporal contour in patients with sequelae of craniosynostosis. This treatment will help boost patients’ self-esteem starting at an early age.
Abdomen ; Adipose Tissue ; Child ; Craniosynostoses* ; Depression ; Follow-Up Studies ; Frontal Bone ; Happiness ; Humans ; Parents ; Plagiocephaly ; Plastics ; Postoperative Period ; Stem Cells* ; Surgeons ; Visual Analog Scale ; Weights and Measures

Progressive facial hemiatrophy, also known as Parry-Romberg syndrome, is a progressive and self-limited deformation of the subcutaneous tissue volume on one side of the face that creates craniofacial asymmetry. We present the case of a patient with a five-year history of progressive right facial hemiatrophy, who underwent facial volumetric restoration using cell-assisted lipotransfer (CAL), which consists of an autologous fat graft enriched with adipose-derived stem cells (ASCs) extracted from the same patient. ASCs have the capacity to differentiate into adipocytes. They also promote angiogenesis, release angiogenic growth factors, and some can survive as stem cells. The use of autologous fat as a filler in soft tissue atrophy has been satisfactory in patients with mild and moderate Parry-Romberg syndrome. Currently, CAL has showed promising results in the long term by decreasing the rate of fat reabsorption. The permanence and stability of the graft in all the injected areas has showed that autologous fat grafts enriched with stem cells could be a promising technique for the correction of defects caused by this syndrome.
Adipocytes ; Atrophy ; Facial Hemiatrophy ; Humans ; Intercellular Signaling Peptides and Proteins ; Stem Cells ; Subcutaneous Tissue ; Tissue Therapy ; Transplants

This document offers guidance to help the ophthalmologist plan for the safe resumption of elective surgical care. There are 4 sections: (I) COVID-19 Awareness, (II) Preparedness, (III) Patient Issues, and (IV) Delivery of Safe and High-Quality Care. Each section contains key issues to be addressed before elective surgery may be safely reinstituted. Understanding the capabilities of health facilities (e.g., testing, operating rooms) as well as the potential limitations in manpower and supplies will remain important, while keeping an eye out on subsequent waves of COVID-19.
COVID-19