correspondence n engl j med 360;26 nejm.org june 25, 2009 2791 es, a growing number of primary care physicians are choosing to refer their patients to hospital- ists, and this number may continue to increase; whether this is in the patients’ best interests is not known. We share Bing’s view that optimal communi- cation among the clinicians caring for patients is crucial. Primary care physicians and hospital- ists should work together to improve care coor- dination and communication. Mary Beth Hamel, M.D., M.P.H. Jeffrey M. Drazen, M.D. Arnold M. Epstein, M.D. Medical Evaluation before Electroconvulsive Therapy To the Editor: Tess and Smetana (April 2 issue) 1 do not include neuroimaging in their routine eval- uation of patients before electroconvulsive thera- py (ECT). However, in areas where the parasite is endemic, silent, undetected neurocysticercosis is a good reason for mandatory neuroimaging be- fore ECT. In Brazil, with the use of computed to- mography (CT), magnetic resonance imaging, or both, we prospectively evaluated 91 consecutive psychiatric outpatients who were candidates for ECT. We identified hidden neurocysticercosis in six patients (7%). We detected active, multiple cystic neurocysticercosis in one patient; inactive, multi- ple neurocysticercosis in two patients; and a single lesion of probable inactive neurocysticercosis in three patients. Active forms of this infection may produce mass effects, and inactive lesions can pro- duce ectopic cerebral activity, 2 interfering with seizure threshold. Both types of lesions can lead to unpredictable risks during ECT. The most fre- quent parasitosis affecting the brain, neurocysti- cercosis is endemic in many poor areas, including China and India, and also in specific populations within developed countries, particularly among migrants and travelers. Psychiatrists may be un- aware of the relevance of this condition. Neuro- cysticercosis is a great imitator, and in endemic areas it should be considered in the psychiatric dif- ferential diagnosis, 3 including that of depressive disorders. 4 Almir R. Tavares, Jr., M.D., Ph.D. Universidade Federal de Minas Gerais 30130-100 Belo Horizonte, Brazil almirtav@medicina.ufmg.br Fernando M. Volpe, M.D., Ph.D. Fundação Hospitalar do Estado de Minas Gerais 30130-100 Belo Horizonte, Brazil Tess AV, Smetana GW. Medical evaluation of patients under- 1. going electroconvulsive therapy. N Engl J Med 2009;360:1437-44. Nash TE, Pretell EJ, Lescano AG, et al. Perilesional brain oe- 2. dema and seizure activity in patients with calcified neurocysticer- cosis: a prospective cohort and nested case-control study. Lancet Neurol 2008;7:1099-105. Tavares AR Jr. Psychiatric disorders in neurocysticercosis. Br 3. J Psychiatry 1993;163:839. Forlenza OV, Filho AH, Nobrega JP, et al. Psychiatric mani- 4. festations of neurocysticercosis: a study of 38 patients from a neurology clinic in Brazil. J Neurol Neurosurg Psychiatry 1997; 62:612-6. To the Editor: In their review on medical evalu- ation of patients undergoing ECT, Tess and Smeta- na recommend that the use of short-acting intra- venous beta-blockers be reserved for patients at high risk for cardiovascular complications. This recommendation is not supported by the avail- able evidence. During a seizure, an intense sym- pathetic discharge is transmitted directly to the cardiovascular system via the spinal sympathetic tract, causing tachycardia, hypertension, and con- duction abnormalities. 1 This sympathetic discharge can cause catastrophic complications if not man- aged properly. 2 Both esmolol and labetalol can re- duce or eliminate tachycardia, hypertension, ec- topy, and ST-segment depression during ECT. 3 Since there is no evidence that beta-blockers re- duce the effectiveness of ECT, and there is clear evidence that they reduce cardiovascular stress dur- ing the treatment, beta-blockade should be admin- istered to all patients undergoing ECT, with the exception of young, healthy persons who are normotensive and known to have normal cardio- vascular reserve and patients with specific con- traindications to beta-blockade. Charles A. Welch, M.D. Massachusetts General Hospital Boston, MA 02114 cwelch1@partners.org Welch CA, Drop LJ. Cardiovascular effects of ECT. Convuls 1. Ther 1989;5:35-43. The New England Journal of Medicine Downloaded from nejm.org on May 10, 2014. For personal use only. No other uses without permission. Copyright © 2009 Massachusetts Medical Society. All rights reserved.