Although the procedures adopted in the cases described in this review are uncommon, they potentially provide an alternative to the discontinuation of clozapine treatment in patients with complex symptomatologies for whom treatment with other antipsychotic medication is insufficient.

PurposeChemotherapy for lung cancer can have a detrimental effect on white blood cell (WBC) and red blood cell (RBC) counts. Physical exercise may have a role in improving WBCs and RBCs, although few studies have examined cancer patients receiving adjuvant therapies. The purpose of this pilot trial was to examine the effects of an exercise intervention utilizing resistance bands on WBCs and RBCs in lung cancer patients receiving curative intent chemotherapy.MethodsA sample of lung cancer patients scheduled for curative intent chemotherapy was randomly assigned to the exercise intervention (EX) condition or usual care (UC) condition. The EX condition participated in a three times weekly exercise program using resistance bands for the duration of chemotherapy.ResultsA total of 14 lung cancer patients completed the trial. EX condition participants completed 79% of planned exercise sessions. The EX condition was able to maintain WBCs over the course of the intervention compared to declines in the UC condition (p = .008; d = 1.68). There were no significant differences in change scores in RBCs.ConclusionsExercise with resistance bands may help attenuate declines in WBCs in lung cancer patients receiving curative intent chemotherapy. Larger trials are warranted to validate these findings. Ultimately these findings could be informative for the development of supportive care strategies for lung cancer patients receiving chemotherapy.Trial registrationClinical Trials Registration #: NCT01130714.

Clozapine, an atypical antipsychotic drug, is associated with a high risk of neutropenia and agranulocytosis, necessitating the immediate discontinuation of the drug. We report the case of a patient who developed clozapine-induced neutropenia. Assessments revealed a pronounced diurnal variation in the number of circulating neutrophils (1200-1900/mm(3) in the morning and 2200-2700/mm(3) in the afternoon). Due to these circadian changes, we decided to continue clozapine treatment.

Sir: Agranulocytosis occurs in 1% to 2% of patients treated with clozapine. Thus, if neutropenia (absolute neutrophil count [ANC] of < 1500/µL) occurs during clozapine treatment, physicians generally interrupt the drug treatment and do not reintroduce it. Lithium and granulocyte colony-stimulating factor may be used to reverse clozapine-induced granulocytopenia. 1 We have previously reported the case of a patient who was able to continue clozapine treatment despite developing "morning pseudoneutropenia" (MPN). 2 In this report, we describe the course of the clozapine treatment over the following 24 months.Case report. In January 2002, clozapine treatment was administered to Mr. A, a 44-year-old white man with DSM-IV paranoid schizophrenia who had previously shown resistance to various other antipsychotics. Prior to treatment, the patient's total white blood cell count (WBC) and ANC were 7100/µL (normal range, 4500-11,000/µL) and 5300/µL, respectively. His clozapine dose was gradually increased to 200 mg/day, leading to a satisfactory improvement in symptoms. Concomitant medication consisted of valproic acid (2000 mg/day).After 27 weeks of clozapine treatment, the patient's WBC and ANC had declined to 4100/µL and 1300/µL, respectively. However, a subsequent physical examination, Mr. A's medical history, and baseline laboratory investigation did not indicate that chronic or acute inflammation or infection, or autoimmunologic or hematologic disease, had developed. After the first blood sample was taken at 8 a.m., a second blood sample was taken at 2 p.m. later that day, and the patient's WBC and ANC were in the normal range (5500/µL and 2200/µL, respectively).Clozapine treatment was continued with a strict hematologic monitoring program: blood tests were performed at 8 a.m. and at 2 p.m. twice a week. During the following 3 weeks, Mr. A's ANCs were persistently between 1200/µL and 1900/µL at 8 a.m. (corresponding WBCs: 4100-4700/µL) and between 2200/µL and 2700/µL at 2 p.m. (corresponding WBCs: 5400-5800/µL).Thereafter, monthly blood tests were systematically performed at 2 p.m. During the following 24 months, the patient's ANCs remained within the normal range. Clozapine treatment was thus continued, and the patient has since shown a great improvement in his social function.Morning pseudoneutropenia is known to occur during clozapine treatment. 2,3 However, due to short follow-up periods in previous reports, the duration and severity of this phenomenon were unknown. On the basis of this and other case reports, 2,3 we hypothesize that MPN is a transient and harmless type of neutropenia rather than an early sign of incipient agranulocytosis.