Fixed-combination brinzolamide 1%/brimonidine 0.2% vs monotherapy with brinzolamide or brimonidine in patients with open-angle glaucoma or ocular hypertension: results of a pooled analysis of two phase 3 studies

Purpose

To describe pooled efficacy and safety data from two phase 3 studies comparing brinzolamide 1%/brimonidine 0.2% fixed combination (BBFC) with its component medications, brinzolamide and brimonidine, in patients with open-angle glaucoma or ocular hypertension.

Methods

Data were pooled from two nearly identical clinical trials comparing BBFC with its component medications, each given three times daily. The 3-month efficacy outcome was mean intraocular pressure (IOP) at 0800, 1000, 1500, and 1700 hours. Safety outcomes included adverse events (AEs), best-corrected visual acuity, examination of ocular structures, pachymetry, perimetry, and vital signs.

Results

A total of 1350 patients were enrolled and included in this analysis (BBFC, n=437; brinzolamide, n=458; brimonidine, n=455). Baseline mean IOP levels were similar among the three treatment groups. At 3 months, mean IOP of the BBFC group was significantly lower than that of either monotherapy group (P<0.0001) at all the four time points. A total of 272 patients (20.1%) experienced at least one treatment-related AE (BBFC, 24.6% brinzolamide, 18.7% brimonidine, 17.4%), the majority of which were ocular AEs. One serious AE, moderate intensity chest pain, was considered related to brinzolamide treatment and resulted in study discontinuation.

Conclusions

This analysis strengthens the conclusions drawn from the two individual phase 3 studies showing that, in patients with open-angle glaucoma or ocular hypertension, BBFC had significantly superior IOP-lowering activity compared with either brinzolamide or brimonidine alone and a safety profile consistent with that of its individual components.

A comparative study of Arab and Jewish patients admitted for psychiatric hospitalization in Jerusalem: the demographic, psychopathologic aspects, and the drug abuse comorbidity

BACKGROUND

The influence of ethnicity on different aspects of psychiatric hospitalization is far from clear.

THE AIM OF THE STUDY

The main aim of the study was to compare the Arab and the Jewish inpatients, at the time of admission, for the demographic factors, severity of psychotic, and affective psychopathology and comorbid drug abuse rate. POPULATION, METHOD, AND TOOLS: Among 250 consecutively admitted patients in the Jerusalem Mental Health Center-Kfar Shaul Hospital, 202 Jews and 42 Arabs (aged 18-65 years) were examined within 48 hours after admission. The psychiatric diagnoses were made according to the criteria of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. For the differential measurement of psychopathologic severity, the following rating scales were used: 21-item Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Positive and Negative Syndrome Scale (PANSS), and Young Mania Rating Scale. Urine tests for Δ9-tetrahydrocannabinol (THC), cocaine, opiates, amphetamines, and methamphetamine were performed using the Sure Step TM kits (Applied Biotech, Inc, San Diego, CA, USA). The Structured Clinical Interview Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for drug abuse were applied based on self-report and results of urine analysis.

RESULTS

The comparison of the 2 population showed that among the Arab inpatients, there were more males (81% vs 67.4%; P < .005). No significant difference in psychiatric diagnosis was observed. The overall severity of positive symptoms (PANSS positive) in Arab group was higher, but only slightly so (P = .05). No significant difference was observed for total rates of PANSS negative subscale. The rates of PANSS-general were also similar. The Arab patients were significantly less depressive according to 21-item Hamilton Depression Rating Scale (P = .032), and the total score of Hamilton Anxiety Rating Scale for the Jewish group was significantly higher (P = .001). No significant difference in general severity of manic symptoms for 2 groups was detected according to Young Mania Rating Scale. The rate of comorbid drug abuse for Jewish inpatients was borderline higher (P = .068).

CONCLUSIONS

The issue of referral to psychiatric hospitalization could be culturally influenced; it may be the result of disparities in demographic, psychopathologic, and drug abuse comorbid presenting symptoms, which are demonstrated upon admission by patients of different ethnic origins.

Maintenance of certification and keys to passing the recertification examination

The American Board of Orthopaedic Surgery requires that each board-certified orthopaedic surgeon recertify every 10 years. This formal procedure of demonstrating competence as a surgeon, which used to be known as recertification, has been replaced by a more comprehensive process termed maintenance of certification (MOC). Even an experienced orthopaedic surgeon may find achieving MOC a daunting prospect. Simply preparing for and taking the recertification examination is an enormous challenge, but it is important to remember that the examination is merely one aspect of maintaining certification. Prior to sitting for the examination, each physician is required to complete the other MOC requirements, including amassing continuing medical education credits, compiling a case list, and soliciting peer recommendations. Familiarity with the MOC process, understanding the details of the examination, and proper preparation techniques will help orthopaedic surgeons gain insights into how to approach MOC.

Tachyphylaxis/tolerance to antidepressants in treatment of dysthymia: results of a retrospective naturalistic chart review study

AIM

The main goals of this chart-review study were to examine the rate of tachyphylaxis during treatment of dysthymia with antidepressants, to compare the incidence of tolerance during trials of selective serotonin reuptake inhibitors (SSRI) and non-SSRI and to give descriptive analysis of the cases of tachyphylaxis.

METHODS

The retrospective naturalistic chart review study included 52 cases of successfully treated (with different antidepressants) patients suffering from dysthymia. The overall number of the cases of tolerance to antidepressants were registered as well as the rate of these phenomena in the groups treated with SSRI and non-SSRI.

RESULTS

The cases of tolerance/tachyphylaxis were observed in 12 patients (23% of patients) and in 13 trials (22.4% of trials). All cases of tolerance occurred during monotherapy. No cases of tachyphylaxis were observed in the non-SSRI group while in the SSRI group, tolerance at some stage of the treatment was detected in 41.9% of the successful cases (P < 0.001).

CONCLUSION

During the treatment of dysthymia with antidepressants in the SSRI group, tachyphylaxis/tolerance might be observed in a relatively in high proportion of cases.

A comparative study of psychiatric inpatients in a general hospital and a psychiatric hospital in Israel: demographics, psychopathological aspects and drug abuse patterns

BACKGROUND

Some specialists and policy makers advocate progression of the mental health reform in Israel by transferring beds from psychiatric to general hospitals.

OBJECTIVES

To compare the demographic, diagnostic and psychopathological profiles of psychiatric inpatients hospitalized in psychiatric and general hospitals, as well as their patterns of drug abuse, and to estimate the preparedness of general hospitals for the possible expansion of their psychiatric services.

METHODS

Between 2002 and 2006 a total of 250 patients were consecutively admitted to the Jerusalem Mental Health Center-Kfar Shaul Hospital and 220 to the psychiatric department of Sheba Medical Center, a general hospital in central Israel; the patients' ages ranged from 18 to 65. The two groups were compared for demographic features, psychiatric diagnoses and severity of psychopathology (utilizing PANSS, HAD-21, YMRS rating scales). Drug abuse was diagnosed by urine analyses and self-report.

RESULTS

The patients in the psychiatric hospital were significantly younger, predominantly male, and more dependent on social security payments. In the general hospital, diagnoses of affective and anxiety disorders prevailed, while in the psychiatric hospital schizophrenic and other psychotic patients constituted the majority. The patients in the general hospital were decidedly more depressed; in the psychiatric hospital, notably higher rates of manic symptoms as well as positive, negative and general schizophrenic symptoms were reported. For the most abused substances (opiates, cannabis and methamphetamines) the rates in the psychiatric hospital were significantly higher.

CONCLUSIONS

The differences between the two groups of inpatients were very pronounced, and therefore, the transferring of psychiatric beds to general hospitals could not be done without serious and profound organizational, educational and financial changes in the psychiatric services of general hospitals. Since each of the two inpatient systems has particular specializations and experience with the different subgroups of patients, they could coexist for a long time.

Tachyphylaxis/ tolerance to antidepressive medications: a review

Tachyphylaxis is the appearance of progressive decrease in response to a given dose after repetitive administration of a pharmacologically or physiologically active substance; the symptoms could appear also during treatment with antidepressants. Although the real frequency of the phenomenon is unclear, it may be as high as 33% during the pharmacological treatment of depression. The review deals with the possible causes and the treatment of the tachyphylaxis following antidepressant treatment.

Medical clearance risk rating as a predictor of perioperative complications after total hip arthroplasty

Hip arthroplasty has become the standard treatment of end-stage osteoarthritis. However, postoperative complications are the risks associated with joint arthroplasty, which most significantly impact patient results and the total cost of care. Currently, no predictive system has been developed for categorizing levels of risk for the development of postoperative complications in patients undergoing total hip arthroplasty. We examined the association between the medical clearance risk rating by the physician performing the preoperative clearance examination and postoperative complications after total hip arthroplasty. We have demonstrated a significant association between the medical clearance risk rating and postoperative urinary track infection, and the American Society of Anesthesiologist score but no significant association to other complications. This study presents a predictive patient characteristic that may help us identify among our patients the ones that may benefit from a personally tailored preoperative planning and evaluation but demonstrates further work is necessary to better predict the risk of complications after total hip arthroplasty.

Ocular surface disease in patients with glaucoma or ocular hypertension treated with either BAK-preserved latanoprost or BAK-free travoprost

Purpose

The preservative benzalkonium chloride (BAK) may adversely affect ocular surface health. This study evaluated symptoms of ocular surface disease (OSD) in patients previously treated with a BAK-preserved therapy to lower their intraocular pressure, who either continued that therapy or switched to a BAK-free therapy.

Methods

Eligible adult patients with ocular hypertension or open-angle glaucoma that had been controlled with BAK-preserved latanoprost 0.005% monotherapy (Xalatan^®) for at least one month and had a score of ≥ 13 (0 = none, 100 = most severe) on the Ocular Surface Disease Index (OSDI) questionnaire were entered into this prospective, double-masked, randomized, active-controlled, multicenter trial. By random assignment, patients either continued with BAK-preserved latanoprost 0.005% or transitioned to BAK-free travoprost 0.004% (Travatan Z^® ophthalmic solution). OSDI scores were assessed again after six and 12 weeks.

Results

For the 678 evaluable patients, mean change in OSDI score from baseline to week 12 favored the travoprost 0.004% BAK-free group, but was not statistically different between groups (P = 0.10). When patients with mild OSD at baseline were assessed after 12 weeks, the mean OSDI score was significantly lower (P = 0.04) in the BAK-free travoprost 0.004% group (score = 11.6 ± 10.8 units) than in the BAK-preserved latanoprost 0.005% group (score = 14.4 ± 11.9 units), and a significantly larger percentage (P < 0.01) improved to normal OSDI scores in the BAK-free travoprost 0.004% group (62.9% of group) than in the BAK-preserved latanoprost 0.005% group (47.0% of group). Patients pretreated with BAK-preserved latanoprost 0.005% for >24 months were significantly more likely (P = 0.03) to improve to a normal OSDI score after 12 weeks if they were switched to BAK-free travoprost 0.004% (47.9% of group) than if they remained on BAK-preserved latanoprost 0.005% (33.9% of group).

Conclusions

Switching from BAK-preserved latanoprost 0.005% to BAK-free travoprost 0.004% yielded significant improvements in symptoms of OSD in patients with glaucoma or ocular hypertension.

Cord blood banking in France: reorganising the national network

Paradoxically, France is one of the leading exporters of cord blood units worldwide, but ranks only 17th in terms of cord blood units per inhabitant, and imports 64% of cord blood grafts to meet national transplantation demands. With three operational banks in 2008, the French allogeneic cord blood network is now entering an important phase of development with the creation of seven new banks collecting from local clusters of maternities. Although the French network of public banks is demonstrating a strong commitment to reorganise and scale up its activities, the revision of France's bioethics law in 2010 has sparked a debate concerning the legalisation of commercial autologous banking. The paper discusses key elements for a comprehensive national plan that would strengthen the allogeneic banking network through which France could meet its national medical needs and guarantee equal access to healthcare.

Cannabis abuse and severity of psychotic and affective disorders in Israeli psychiatric inpatients

The influence of cannabis abuse on the severity of existing psychotic and affective symptoms is still unclear. Among 470 consecutively admitted psychotic or affective patients, 54 active (in the previous month) cannabis abusers were detected via urine tests (Sure Step TM kits; Applied Biotech Inc, San Diego, Calif) and Structured Clinical Interview for DSM-IV (SCID- IV) questionnaire. In 24 cases, substances other than cannabis were abused; 392 patients were nonabusers. All patients were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. The following rating scales were used: Hamilton Depression Rating Scale (HAM-D-21), Positive and Negative Syndrome Scale (PANSS), and Young Mania Rating Scale (YMRS). Cannabis abusers (n = 54) were significantly younger and more frequently males than nonuser patients. In this group, there were more schizophrenic patients and fewer affective and anxiety patients (chi(2) = 11.76; P < .01). The double-diagnosed patients had more prominent psychotic symptoms than the nonusers (n = 392)-PANSS positive: 19.056 +/- 8.30 vs 16.128 +/- 8.031 (P < .02; t(446) = 2.510). The difference was statistically significant for hallucinatory behavior, excitement, grandiosity, and hostility. General PANSS scale rate of abusers was lower: 33.012 +/- 9.317 vs 37.3575 +/- 11.196 (P < .01; t = 2.727), especially for depression, anxiety, somatic concern, guilt feelings, tension, motor retardation, and volition disturbances. Rates of PANSS negative scale of abusers and nonusers were not significantly different (13.815 +/- 6.868 vs 14.983 +/- 6.446) except for lower rates of social withdrawal and stereotyped thinking for abusers. No significant difference in general level of manic symptoms (YMRS) between abusers and nonusers was observed (6.778 +/- 10.826 vs 4.910 +/- 7.754), but severity of thought/language disturbances and poor insight was found significantly higher in the abusers. Cannabis abusers are obviously less depressive (HAM-D): 5.944 +/- 10.291 vs 12.896 +/- 13.946 (P < .0005, t = 3.535). Such differences were observed in the high number of the subscales. Abusers' rates were higher (although not significantly) for paranoid symptoms and general somatic symptoms. Cannabis possibly produces some antidepressive and anxiolytic effect on psychotic and affective inpatients. The "price" of this effect is often an exacerbation of psychotic and some manic symptoms.

NRP/B mutations impair Nrf2-dependent NQO1 induction in human primary brain tumors

Brain tumors are associated with genetic alterations of oncogenes and tumor suppressor genes. Accumulation of reactive oxygen species (ROS) in cells leads to oxidative stress-induced damage, resulting in tumorigenesis. Here, we showed that the nuclear matrix protein nuclear restricted protein in brain (NRP/B) was colocalized and interacted with NF-E2-related factor 2 (Nrf2). During oxidative stress response, NRP/B expression and its interaction with Nrf2 were upregulated in SH-SY5Y cells. Association of NRP/B with Nrf2 was crucial for NAD(P)H:quinone oxidoreductase 1 (NQO1) expression. NRP/B was localized predominantly in the nucleus of normal brain cells, whereas in primary brain tumors NRP/B was almost exclusively contained in the cytoplasm. In addition, unlike wild-type NRP/B, the expression of NRP/B mutants isolated from primary brain tumors was found in the cytoplasm, and these mutants failed to induce Nrf2-dependent NQO1 transcription. Thus, NRP/B mutations and their altered localization resulted in changes in NRP/B function and deregulation of Nrf2-dependent NQO1 activation in brain tumors. This study provides insights into the mechanism by which the NRP/B modulates Nrf2-dependent NQO1 induction in cellular protection against ROS in brain tumors.

Case report: successful use of hyperbaric oxygen therapy for a complete scalp degloving injury

We report a case of a complete scalp degloving injury in a 43-year-old previously healthy, tobacco-using female whose hair was caught in a tractor power take-off causing an instantaneous total scalping injury. Microsurgical replantation was started 4 hours after injury with the surgical procedure lasting 4 hours. Only the superficial temporal arteries were reanastomosed with no venous anastomosis possible. Hyperbaric oxygen (HBO2) treatment at 2.5 atmospheres absolute (ATA) for 90 minutes was administered immediately after surgery due to duskiness of the flap. Further HBO2 treatments were administered twice daily for seven days and then once daily for 30 days. Additionally, leech therapy was used for the first ten postoperative days. The patient's right auricle and most of the left auricle were completely lost. Despite the tenuous vascular inflow and initially absent venous drainage, at 3 month follow-up there was reepithelialization of her scalp except for an area of granulation tissue in the occipitoparietal area. At one year follow-up the area of granulation tissue was reduced, but there was no detectable hair growth or nerve function. We propose that HBO2 may facilitate tissue survival in scalp degloving injuries in the face of incomplete surgical revascularization.

Substance abuse in hospitalized psychiatric patients

BACKGROUND

The co-morbidity rate of illicit substance abuse and major mental problems in Israel is far from clear.

OBJECTIVES

To investigate the extent of drug abuse in a sample of psychiatric patients hospitalized in a psychiatric hospital and in the psychiatric department of a general hospital in Israel, to compare demographic and other background factors in dual-diagnosis patients with those of abuse-free mental inpatients, and to examine the time correlation between drug abuse and the appearance of major mental problems.

METHODS

Our data were derived from self-report and urine tests. The study population comprised 470 consecutively admitted patients--250 patients in the mental health center and 220 patients in the psychiatric department of the general hospital.

RESULTS

The lifetime prevalence of drug abuse was 24%; cannabis abuse was found in 19.7%, opiates in 5.7%, cocaine in 2.7%, amphetamines in 3.4% and methamphetamine in 1.1%. Active abuse of drugs (during the last month) was registered in 17.3%, cannabis in 11.5%, opiates in 4.9%, amphetamine in 3.8%, cocaine in 1.3% and methamphetamine in 1.1%. We also found that 28.2% of active abusers used two or more substances. In 41.6% the drug abuse appeared prior to symptoms of the mental disorder; in 37.1% the duration of the mental disorders and the drug abuse was relatively similar, and in 21.3% of cases the duration of mental problems was longer than the duration of drug abuse. Dual-diagnosis patients were younger than non-abusers, more often male, unmarried, and of western origin.

CONCLUSIONS

Substance abuse (especially cannabis) among hospitalized psychiatric patients in Israel is a growing problem.

[Multisensory environmental intervention (snoezelen) as a preventive alternative to seclusion and restraint in closed psychiatric wards]

Seclusion and restraint, unfortunately, still remain a routine practice in closed psychiatric wards worldwide and in Israel. These practices often lead to distress, traumatized patients, and further increase the negative view and stigmatization of psychiatric treatment and, most especially, psychiatric hospitalization. Multisensory environmental intervention, Snoezelen, combines sensory integration theory with a client-oriented approach. Snoezelen treatment calms and relaxes agitative patients giving them a feeling of dignity, initiative and freedom of choice. The Snoezelen room is a high-tech, multisensory environment that includes music, light of fiber optic strands, calming image projections, vibrations of bubbles tubes, and soothing smells. After 30 to 40 minutes of exposure to Snoezelen, agitative patients in our closed ward reported substantial reduction of their distress level and, outwardly, appeared less agitated and displayed less aggressive and hostile behavior. Foremost, since the beginning of the multisensory environmental interventions in the closed wards, a statistically significant reduction in the number of restraints and seclusions has occurred in the closed male section in comparison to the closed female section, where snoezelen has not been administered (P < 0.05).

IN CONCLUSION

Snoezelen is an innovative and preventative alternative to seclusion and restraint in closed psychiatric settings. It produces a calming effect on agitative patients, reduces the length of time and number of seclusions and restraints, and diminishes the stigma against psychiatric treatment and hospitalization.

Ocular hypotensive efficacy of travoprost in patients unsuccessfully treated with latanoprost

OBJECTIVE

To evaluate the efficacy of travoprost 0.004% monotherapy in patients unsuccessfully treated with latanoprost monotherapy.

RESEARCH DESIGN AND METHODS

Open-label, noncomparative study conducted at US academic and private practice clinics in adult patients with ocular hypertension or primary open-angle glaucoma who required a change in therapy (due to either inadequate efficacy or safety issues) as judged by the investigator. Intraocular pressure (IOP) was measured at entry and 30 days later.

MAIN OUTCOME MEASURES

Mean change in intraocular pressure (mm Hg).

RESULTS

Reported here are 488 per-protocol patients from 330 centers who were using latanoprost monotherapy prior to study entry, and who received travoprost monotherapy during the study. Patients had a mean age of 69 years, were approximately two-thirds Caucasian, 60% female, predominantly brown or blue eyes, and 91% were diagnosed as having primary open-angle glaucoma. The mean days in treatment were 31.9 +/- 6.4. Mean IOP at study entry was 21.2 mm Hg. Following travoprost monotherapy, this was reduced by a mean of 3.2 mm Hg to 18 mm Hg (p < 0.0001, paired t-test). There were 21 adverse events reported in the intent-to-treat (ITT) population for an incidence of 3.5%. There were some limitations to the current study including: no washout period, no control therapy, single IOP determinations at the beginning and the end of the study; patient compliance with the initial therapy was not measured, and the study was not masked. This study reflects a real-life situation of what a clinician can expect when he changes a patient from latanoprost monotherapy to travoprost monotherapy.

CONCLUSION

This study showed that travoprost provided a statistically and clinically significant reduction (p < 0.0001) in IOP of 3.2 mm Hg for patients who had not been successfully treated with latanoprost monotherapy. The results of this trial demonstrate the potential benefit of using travoprost as a replacement therapy in order to ensure adequate IOP control.