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PubMed1993

Problem severity and symptomatology among substance misusers: differences between African-Americans and Caucasians.

Using data collected on 348 patients presenting to a hospital-based substance misuse treatment program, the present study compares psychiatric symptomatology and severity of substance misuse among African-American and Caucasian alcohol and drug misusers. African-Americans had a higher overall severity of substance misuse and reported using more substances than Caucasians. African-Americans also had higher levels of somatization, interpersonal problems, depression, hostility, obsessive/compulsive behavior, phobia, paranoia, and psychoticism than Caucasians. African-Americans exhibited higher levels of psychosocial stress and lower levels of global functioning than did Caucasians. The implications of the findings are discussed.

Adult↗

PubMed1997

Quality of life after knee arthroplasty. A randomized study of 3 designs in 42 patients, compared after 4 years.

We assessed different yardsticks for outcome 4 (3-5) years after surgery in a prospective, randomized study of 42 patients, where 3 designs of cemmentless knee prostheses were used. The prognosis with regard to loosening, previously obtained by radiostereometry after 2 years of follow-up, was utilized. Patients with a prognosis of stable implant fixation (two thirds) were compared with those where loosening was predicted (one third). Hospital for Special Surgery score and Visual Analogue Scales regarding pain at rest, "first step" pain, pain during activity and global function, showed consistent postoperative improvements, but no differences between the design and prognosis groups were found. Radiolucent lines were registered both as yes/no and number of zones. Lines and prognosis were associated, but not lines and design groups. Quality of life assessment by the Nottingham Health Profile questionnaire showed that the poor prognosis group had increased pain and significant disturbances of sleep and emotions, as well as difficulty in enjoying hobbies and holiday activities. No differences were found between the design groups. Altogether, the patients showed profiles comparable to a healthy reference group. We conclude that the Nottingham Health Profile is a sensitive, relevant and simple measure of outcome after knee arthroplasty.

Activities of Daily Living↗

PubMed2004

[Current therapies in dementia].

Currently, cholinergic therapies for Alzheimer's disease (AD) have been developed and widely accepted based upon an observation that presynaptic cholinergic neurons in the basal nucleus of Meynert that widely project to the cerebral cortices are consistently damaged in AD brains. Since it is likely that the loss of central cholinergic activity may be associated with cognitive worsening in patients with AD, it is hypothesized that cholinergic augmentation could improve the cognitive ability of patients with AD. Cholinesterase inhibitors represent one way of implementing this strategy by inhibiting the breakdown of acetylcholine and increasing its availability in synapses. Indeed, several recent clinical trials of donepezil, galanthamine and rivastigmine have come to the conclusion that these cholinesterase inhibitors have overall beneficial effects in cognitive as well as global functions. American Academy of Neurology recommended a use of cholinesterase inhibitors as a first choice medicine in the treatment of AD. All 3 major studies of Donepezil from USA, Europe and Japan have reached the same conclusion favoring Donepezil in the treatment of mild to moderate AD. Donepezil can also be used as a safe and efficacious drug in the elderly aged 85 or older. Clinical trial of galantamine is in progress in Japan. Moreover, herbal medicines named kami-untan-to and hachimi-jiou-gan have been shown to be beneficial in some priority studies with a small sample size. It is critically needed to widen therapeutic windows in the treatment of AD.

Aged↗

PubMed1998

Microvascular integrity as a predictor of left ventricular remodeling after acute anterior wall myocardial infarction.

The purpose of this study was to investigate the relation of microvascular integrity and ventricular remodeling after acute myocardial infarction. Twenty-six patients with first acute anterior myocardial infarction were studied before discharge with myocardial contrast echocardiography (MCE). Opacification index (OI) and wall motion index were calculated in the left anterior descending artery territory and left ventricular diastolic volume was measured at baseline and during a 9-month follow-up. In total 26 patients, the regional wall motion improved but the left ventricular volume and global function was not changed significantly at follow-up. When the patients were divided into 3 groups according to opacification index (> or = 0.75, 0.5 approximately 0.75, < or = 0.5) at baseline, functional recovery was not observed and significant left ventricular dilatation was developed in patients with < or = 0.5 OI. Among the baseline echo-parameters such as ejection fraction, wall motion score, left ventricular volume and opacification index, the best predictor for long term left ventricular dilatation was the opacification index by multivariate analysis. In patients with acute anterior wall infarction the assessment of microvascular integrity by MCE at acute stage provides useful information regarding recovery of dysfunctional regional wall motion and ventricular remodeling.

Coronary Vessels↗

PubMed2006

Use of antidementia agents in vascular dementia: beyond Alzheimer disease.

Vascular dementia (VaD) is the second leading cause of dementia and is often underdiagnosed. Stroke is the leading cause of VaD, although it may also develop secondary to a variety of other cerebrovascular or cardiovascular conditions. Currently, no drugs are approved for the treatment of VaD. However, because cholinergic deficits have been found in patients with VaD, similar to those found in patients with Alzheimer disease (AD), it is believed that cholinesterase inhibitors, which are indicated for the treatment of mild to moderate AD, may also provide benefit for patients with VaD. Clinical trials of donepezil, galantamine, and rivastigmine have supported this idea, although as yet, large-scale, prospective studies in VaD have only been reported for donepezil. Donepezil was shown to provide benefits in cognition, global function, and activities of daily living compared with placebo. The N-methyl-D-aspartate receptor antagonist memantine may also provide some cognitive benefit in VaD, particularly in patients with more advanced disease. These data suggest that antidementia drugs currently used for treatment of AD should be considered for treatment of VaD as well.

Cholinesterase Inhibitors↗

PubMed1997

Fluoxetine treatment of patients with major depressive disorder who failed initial treatment with sertraline.

BACKGROUND: This study was conducted to determine if patients with major depressive disorder who had previously failed treatment with one serotonin selective reuptake inhibitor (SSRI) would respond to a different SSRI. METHOD: Adult outpatients (N = 106) with DSM-III-R major depressive disorder and a history of either intolerance (N = 34) or nonresponse (N = 72) to treatment with sertraline were treated with fluoxetine (mean dose = 37.2 mg/day) in a standardized, open-label, 6-week clinical trial. Outcome was assessed at each visit using the Hamilton Rating Scale for Depression (HAM-D), the Clinical Global Impressions (CGI-Improvement and CGI-Severity) scales, and the Patient's Global Improvement (PGI) scale. RESULTS: Ninety-one patients (86%) completed the study. Sixty-seven patients (63%) responded to fluoxetine (i.e., experienced > or = 50% reduction in HAM-D28 total score at endpoint versus baseline). In addition, clinically and statistically significant improvements were noted on all measures of depressive symptoms and global functioning. There was a nonsignificant trend for patients with a history of less vigorous sertraline trials to respond more favorably to fluoxetine. Fluoxetine therapy was generally well tolerated, and there were only slight differences in adverse events reported by patients who had been intolerant to sertraline versus those who were nonresponders. CONCLUSION: These findings indicate that fluoxetine and sertraline, two widely used SSRIs, are not interchangeable. Patients who either have had trouble tolerating or have not responded to sertraline may do well on fluoxetine treatment.

1-Naphthylamine↗

PubMed1999

A comparative effectiveness study of risperidone and olanzapine in the treatment of schizophrenia.

BACKGROUND: Risperidone and olanzapine have each been demonstrated to be efficacious and safe in the treatment of patients with chronic schizophrenia. To evaluate their relative effectiveness, and to better understand the advantages and limitations of each neuroleptic during actual clinical use, we compared one directly against the other. METHOD: Forty-two subjects with DSM-IV schizophrenia had received open-label treatment with either risperidone or olanzapine. Symptoms, global functioning, and extrapyramidal side effects before and after acute treatment were compared within and across groups. At 6-month follow-up, the relative effectiveness of these 2 atypical neuroleptics on symptoms and quality of life were further evaluated. RESULTS: Following an average of 4 weeks of acute treatment, both risperidone and olanzapine were effective in reducing negative, psychotic, and disorganized symptoms. Although both neuroleptics were associated with low occurrence of treatment-emergent parkinsonism, risperidone was more likely to induce akathisia. The measures for parkinsonism were no different across treatment groups, even after taking into account the higher rate of anticholinergic use in the risperidone group. Following 6 months of treatment with these 2 atypical neuroleptics, there was a significantly greater reduction in psychotic symptoms among risperidone-treated subjects. Otherwise, risperidone and olanzapine appear to be equally effective in reducing disorganized and negative symptoms and in improving the quality of life. CONCLUSION: Risperidone and olanzapine were equally effective as acute treatments. Risperidone was more effective for treatment of psychotic symptoms at 6 months, but otherwise the 2 medications were equally effective in the routine clinical care of patients with schizophrenia. If low (<6 mg/day) doses of risperidone are used, the 2 medications have comparable rates of parkinsonian side effects.

Adult↗

PubMed2004

Combined dialectical behavior therapy and fluoxetine in the treatment of borderline personality disorder.

BACKGROUND: This study examines the therapeutic effect of fluoxetine, a selective serotonin reuptake inhibitor, added to dialectical behavior therapy (DBT), an empirically supported psychosocial therapy, for the treatment of borderline personality disorder. METHOD: This is a 12-week, randomized, double-blind, placebo-controlled study of patients with borderline personality disorder (identified using the Structured Clinical Interview for DSM-IV Axis II Disorders). All subjects received individual and group DBT. Of the 20 subjects that completed treatment, 9 were randomly assigned to receive up to 40 mg/day of fluoxetine and 11 were randomly assigned to the placebo condition. Subjects were evaluated at baseline and at week 10 or 11 on self-report measures of depression, anxiety, anger expression, dissociation, and global functioning. The study was conducted between January 1998 and February 2000. RESULTS: Time-by-group interaction effects revealed no significant group differences in scores from pre-treatment to posttreatment on any measure. However, within the DBT/placebo group, there were significant pretreatment/posttreatment differences in the direction of improvement on all measures. No significant pre-treatment/posttreatment differences were found within the DBT/fluoxetine condition. CONCLUSION: The data suggest that adding fluoxetine to an efficacious psychosocial treatment does not provide any additional benefits. Further studies with larger sample sizes are warranted.

Adult↗

PubMed2002

Possible Link Between Attention-Deficit/Hyperactivity Disorder and Reproductive Complications.

BACKGROUND: Initially conceptualized as a disorder of childhood, attention-deficit/hyperactivity disorder (ADHD) is now emerging as a chronic disorder that may present in adolescence and persist into adulthood. Failure to recognize this common disorder in childhood may lead to disabling comorbid symptoms and a poor long-term prognosis in adulthood. Young adults with undiagnosed ADHD experience significant psychiatric comorbidity, including high rates of drug dependency and lower levels of global functioning. The public health consequences of poor impulse control (e.g., delinquency, criminal activity, drug use, risky sexual behaviors, high-risk pregnancies) are emerging, and a link between ADHD and poverty seems highly probable. CASE REPORT: I explore the sexual behaviors, and their consequences, of a young adolescent female. Her reproductive complications led me to consider undiagnosed ADHD. CONCLUSION: The long-term prognosis when ADHD is unrecognized and untreated in the adolescent is discouraging: maternal and perinatal morbidity may be anticipated and are biologically plausible. The actual assessment of risk in the setting of pregnancy and unrecognized ADHD remains largely unknown, and the benefits of timely diagnosis and appropriate treatment of ADHD during pregnancy have yet to be addressed. The following case presentation suggests an association between undiagnosed ADHD and reproductive complications.

Journal Article↗

PubMed2003

Duloxetine: A New Treatment for the Emotional and Physical Symptoms of Depression.

BACKGROUND: Depression is underdiagnosed in the primary care setting. Physical symptoms such as aches, pains, and gastrointestinal disturbance are frequently associated with major depressive disorder (MDD) and are often the presenting symptoms. Duloxetine, a dual-reuptake inhibitor of serotonin and norepinephrine, may have a positive effect on physical symptoms in addition to efficacy in treating emotional symptoms of depression. METHOD: Efficacy was evaluated in 6 double-blind, placebo- and/or active comparator-controlled trials of duloxetine for patients with MDD (DSM-IV criteria). Efficacy in depression was determined primarily using the 17-item Hamilton Rating Scale for Depression (HAM-D-17). Secondary efficacy measures included subscales of the HAM-D-17 and assessment of physical symptoms. Safety evaluations included adverse events, vital signs, laboratory analyses, and electrocardiograms. Safety was evaluated by pooling the data from the MDD trials and a study of duloxetine in nondepressed patients. RESULTS: Duloxetine demonstrated significant differences from placebo on core mood symptoms, physical symptoms (e.g., back pain), and global functioning as early as week 1 of treatment. The estimated probabilities of remission in the studies that demonstrated efficacy ranged from 43% to 57%. The most frequently observed adverse events for duloxetine-treated patients included nausea, dizziness, insomnia, fatigue, and somnolence. Duloxetine did not prolong corrected QT intervals, and the rate of sustained elevations of blood pressure did not differ significantly from placebo. CONCLUSION: In these studies, duloxetine was safe and effective in the treatment of both emotional and physical symptoms of MDD. Based on dose assessments, 60 mg q.d. appears to be the optimum starting and therapeutic dose.

Journal Article↗

PubMed2006

Standard wound coverage techniques for extremity war injury.

Reconstruction of extremity war injuries begins with aggressive forward resuscitative care and stabilization of the trauma patient. After serial care in progressively better supported medical environments, definitive management is done at the level V military treatment facility. Aggressive forward care coupled with rapid air transport has enabled increasingly complex care to be administered at the continental United States military facilities; however, it has also made the decision between limb salvage and amputation more challenging. Yet to be determined are (1) the optimal timing of definitive wound closure or coverage in coordination with fracture stabilization and (2) the optimal types of flap for both upper and lower extremity reconstruction. Records of patients with complex lower and upper extremity wounds who were treated at the National Naval Medical Center between September 2004 and June 2006 reveal useful short-term data. Longer-term data, such as fracture union rate, time to ambulation, range of motion and global function of salvaged limbs, patient satisfaction with limb salvage, and average cost, are not yet available.

Bandages↗

PubMed2004

[Analysis of the cost and the effectiveness of a psychotherapy for panic disorder with agoraphobia (PDA) versus a treatment combining pharmacotherapy and psychotherapy].

Pharmacotherapy and cognitive-behavioral therapy (CBT) are efficient treatments for Panic disorder with agoraphobia (PDA) yet they remain expensive. This study aims to compare the cost/effectiveness ratio of a CBT for PDA versus a combined treatment of CBT and pharmacotherapy. Eighty-four people followed a CBT either alone or combined with medication. They have been evaluated before treatment, immediately after, as well as one and two years later. The therapy efficacy is calculated at each assessment according to a "Global Functioning Index". Direct and indirect costs are calculated with the "Health Cost Interview". Results suggest that both treatments are equally effective. However, CBT alone is less expensive than CBT with pharmacotherapy. Thus, it offers a better cost-effectiveness ratio that even increases in the long term.

Adult↗

PubMed1997

[Influence of locus coeruleus stimulation on the vagal-cardiovascular reflex].

Experiments were performed on 36 anesthetized rabbits. By cervical vagal afferent stimulation (VAS) with lower electric frequency (5-8 Hz) and higher electric frequency (50-100 Hz), the depressor and pressor responses were established. Both of these responses accompanied by decreasing in renal sympathetic activity (RSA). With the parameters of vagal-pressure reflex and vagal-sympathetic stimulation reflex, effects of stimulation of the locus coeruleus on these were investigated. The vagal-pressure and sympathetic reflexes were significantly inhibited by electric and chemical (glutamate) stimulation of the locus coeruleus. Meanwhile both the electric and chemical stimulation of the locus coeruleus per se elicited the elevation of BP and RSA. These results together with the recently hypothesized global function of the locus coeruleus were discussed.

Animals↗

PubMed1999

A multicentre, randomized, double-blind, placebo-controlled study to evaluate the efficacy, tolerability and safety of two doses of metrifonate in patients with mild-to-moderate Alzheimer's disease: the MALT study.

BACKGROUND: Metrifonate is a long-lasting acetylcholinesterase inhibitor being developed for the symptomatic treatment of Alzheimer's disease (AD). OBJECTIVES: This study compared the efficacy, tolerability and safety of two doses of metrifonate in patients with mild-to-moderate AD, over a 26-week treatment period. METHODS: Six hundred and five patients were randomized to placebo (n=208), a 40/50 mg dose (40 or 50 mg by weight; n=200) or a 60/80 mg dose (60 or 80 mg by weight; n=197) metrifonate. Patients randomized to receive metrifonate were administered a once-daily loading dose of 80 or 120 mg based on weight for 2 weeks, followed by the relevant maintenance dose for 24 weeks. Four main clinical domains of AD were assessed: cognition (ADAS-cog and MMSE), psychiatric and behavioural symptoms (ADAS-noncog and NPI), instrumental and basic activities of daily living (DAD) and global functioning (CIBIC-plus, CIBIS-plus and GDS). RESULTS: ADAS-cog performance was significantly improved in the 60/80 mg and 40/50 mg dose groups, compared with placebo, in the intention-to-treat (ITT) population. In addition, statistically significant treatment differences were demonstrated between the 60/80 mg dose group and placebo on MMSE, ADAS-noncog, the NPI subitems of hallucinations and apathy, DAD, CIBIC-plus, CIBIS-plus and the GDS. The performance of the 40/50 mg dose group was also significantly superior to placebo on the CIBIS-plus and the NPI subitem aberrant motor behaviour. CONCLUSIONS: Metrifonate significantly improved a wide range of symptoms across all four clinical domains of AD in a dose-dependent manner, and was safe and well tolerated at both doses studied.

Activities of Daily Living↗

PubMedDate not supplied

Clinical trials of propentofylline in vascular dementia. European/Canadian Propentofylline Study Group.

The neuroprotective glial cell modulator propentofylline has been used in clinical trials involving more than 800 patients with vascular dementia (VaD). These data derive from two sources: a pooled group of VaD patients from four early phase III European trials, and a multinational European/Canadian phase III study (MN 305) that features a combined randomized withdrawal/delayed onset of progression design to evaluate the effect of propentofylline on disease progression. In the pooled studies, DSM-III-R criteria, Hachinski Ischemia Scores, computed tomography (CT), and magnetic resonance imaging (MRI) were used to select subjects with mild-to-moderate disease; in MN 305, National Institute of Neurological Disorders and Stroke/Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN) criteria and neurologic examinations (including CT and MRI scans) were used to select patients with possible or probable VaD. The use of a central rater to assess cerebrovascular disease in neuroradiologic examinations for study MN 305 was considered to be a key feature for reducing the heterogeneity of the VaD patient population. In addition, the inclusion of patients with possible VaD in this trial greatly increased the number of eligible patients; subgroup analyses revealed no substantial differences between patients with probable versus possible VaD, justifying their inclusion in the study. VaD patients exhibited a more pronounced placebo response in global assessments compared with the Alzheimer disease population in a parallel study. In addition, they experienced less deterioration over time with respect to cognitive and global assessments. Beneficial effects of propentofylline were consistently demonstrated in the domains of cognitive and global function for both VaD populations; however, no treatment benefits could be demonstrated for activities of daily living, possibly due to factors relating to the study population/design, the lack of a validated test instrument for such patients, the caregiver-related phenomenon of "tutoring," or the nature of the disease itself.

Cerebrovascular Disorders↗

PubMed1999

Therapeutic standards in Alzheimer disease.

Donepezil is an effective, well-tolerated, and easily administered symptomatic treatment for mild-to-moderate Alzheimer disease (AD). Data from Phase III clinical trials have demonstrated that donepezil improves cognition, global function, and activities of daily living. In addition, there were no clinically significant treatment-related effects on vital signs or laboratory values in any trial. Adverse events, when present, were generally mild in intensity, transient, and resolved during continued treatment with donepezil. This favorable safety profile, together with its reported clinical benefits established donepezil as one standard of AD therapy. Vitamin E is one of two anti-oxidant therapies that may help to slow the progression of AD over at least a two-year period. One large-scale clinical trial suggests that it has sufficient benefit and safety to join donepezil as a current standard of AD therapy.

Activities of Daily Living↗

PubMedDate not supplied

[Vegetative states: a syndrome in search of a new name].

OBJECTIVES: 1. To critically analyze the concept of 'vegetative' state and a number of reasons that seem to justify the abandonment of this term. 2. To propose a new conceptual approach to the syndrome and, based on this approach, a new terminology. DEVELOPMENT: The concept of 'vegetative' state became popular in the medical literature, in the context of a 'neocorticalist' theory of consciousness. Its clear-cut simplicity and the prestige of its proponents contributed to this acceptance. However, this concept seems to be neurologically and philosophically inappropriate. In addition, in recent years a number of studies have shown that these states are frequently misdiagnosed, due mainly to their inherent complexity. Thus, the need for a new name for this syndrome has become increasingly evident. A conceptualization of the brain global functioning leads to a redefinition of these states. The 'syndrome of brain dismetafunction' is conceptually defined. This term does not have a pejorative connotation. It respects the inherent uncertainty associated to the subjective dimension of consciousness as well as to the prognosis of these states. It promotes an integrative approach to problems related to the diagnosis, treatment, and rehabilitation of these patients. CONCLUSION: It seems pertinent to propose the abandonment of the term 'vegetative' both as conceptually equivocal and as a term that may become a self-fulfilling prophecy. Moreover, a no less important reason to abandon this qualifier is the possibility of a more coherent conceptualization of this syndrome. As a consequence, this approach leads to a new terminology.

Humans↗

PubMed2000

Efficacy of sacroiliac corticosteroid injections in patients with inflammatory spondyloarthropathy: results of a 6 month controlled study.

OBJECTIVE: To evaluate changes in articular symptoms, spinal mobility, and global function over 6 months after intraarticular injections of long acting corticosteroid into the sacroiliac (SI) joints of patients with inflammatory low back pain (ILBP). METHODS: Nineteen patients with symptoms of ILBP were studied. Thirteen (68%) had radiographic evidence of sacroiliitis. The remaining 6 patients (32%) had normal imaging studies and thus were considered to have mechanical low back pain. All patients received bilateral SI joint injections of triamcinolone hexacetonide (40 mg/joint) under computer tomographic guidance. Outcome variables included the duration of low back morning stiffness, back pain (by visual analog scale, McGill Pain Questionnaire), spinal mobility (chest expansion, Schober test, 10 cm segments test, finger-fibula distance), and self-report health status (SF-36). RESULTS: Both groups of patients showed a transient improvement in stiffness and pain, spinal mobility, and general health status that was most pronounced at 1-3 months after intraarticular therapy. This did not reach statistical significance (p > 0.05) and by 6 months, followup all outcome variables had reverted to pretherapy levels in both groups. CONCLUSION: These preliminary observations suggest that SI corticosteroid injections are ineffective in the management of patients with inflammatory spondyloarthropathy.

Administration, Topical↗