Current Management of Schizophrenia: Antipsychotic Monotherapy versus Combination Therapy

We investigated the current practice for treatment of schizophrenia. According to our data, 47 percent of patients with schizophrenia are treated with only antipsychotic medication. An additional 43 percent of patients receive one additional class to supplement their antipsychotic medication, and 10 percent of patients are prescribed two or more classes of drugs in addition to an antipsychotic medication. The most common classes used to supplement antipsychotic medications in the management of schizophrenia include antidepressants (28%), mood stabilizers (18%), agents to treat extrapyramidal symptoms (7%), and sleep aids (5%).

Treatment of depression: antidepressant monotherapy and combination therapy

We investigated the use of antidepressants in the treatment of depression. According to our data, antidepressants are most commonly used alone (85%); however, the prevalence of antidepressant monotherapy decreases as the physician's impression of patient severity increases (92% mild, 84% moderate, 73% severe). Psychiatrists are more likely to use antidepressant combinations than primary care physicians (32% vs. 8%). With respect to combination therapy, the most likely agent to be used in combination with an antidepressant in the treatment of depression was another antidepressant (6.4%); followed by anxiety agents (5.2%), antipsychotics (2.4%), and mood stabilizers and sleep aids (1.2% each). An expert commentary on the data is provided.

Kidney transplantation in abnormal bladder

Structural urologic abnormalities resulting in dysfunctional lower urinary tract leading to end stage renal disease may constitute 15% patients in the adult population and up to 20-30% in the pediatric population. A patient with an abnormal bladder, who is approaching end stage renal disease, needs careful evaluation of the lower urinary tract to plan the most satisfactory technical approach to the transplant procedure. Past experience of different authors can give an insight into the management and outcome of these patients. This review revisits the current literature available on transplantation in abnormal bladder and summarizes the clinical approach towards handling this group of difficult transplant patients. We add on our experience as we discuss the various issues. The outcome of renal transplant in abnormal bladder is not adversely affected when done in a reconstructed bladder. Correct preoperative evaluation, certain technical modification during transplant and postoperative care is mandatory to avoid complications. Knowledge of the abnormal bladder should allow successful transplantation with good outcome.

Endothelial function and arterial stiffness in uncomplicated type 1 diabetes and healthy controls and the impact of insulin on these parameters during an euglycemic clamp

BACKGROUND

In addition to its role in glucose metabolism, insulin has shown to exert numerous vascular effects, and an impaired vascular function of insulin is assumed to be a major contributor in the development of vascular complications. Arterial augmentation (AP) and the augmentation index (Aix) are surrogate parameters of arterial stiffness and are commonly used as predictors for cardiovascular risk. The aim of this study is to investigate the effect of insulin on arterial stiffness and parameters of endothelial function in patients with type 1 diabetes and healthy control subjects.

METHODS

Fourteen patients with type 1 diabetes (six male, eight female) with a mean age of 36.6 +/- 11.8 years and 14 healthy subjects (seven male, seven female) with a mean age of 27.3 +/- 5.5 years were randomized to an euglygemic clamp with either a low (0.25 mU/kg/min) or a high (1.0 mU/kg/min) insulin dose on two different days. The mean HbA1c in the diabetic subjects was 7.3 +/- 0.7%. In these subjects, arterial stiffness was measured by pulse wave analysis (SphygmoCor, AtCor Medical, Australia). AP was calculated as the difference between the second and the first systolic shoulders of the central pressure wave curve, and the Aix was expressed as the percentage of AP from total pulse pressure. As parameters of endothelial function, cyclic guanosine monophosphate, nitrotyrosine, and asymmetric dimethylarginine were determined at baseline and after 120 minutes.

RESULTS

Patients with type 1 diabetes showed increased values for AP with 3.5 +/- 3.1 mm Hg and Aix with 12.5 +/- 12.5% compared to healthy controls with -0.7 +/- 2.6 mm Hg for AP and -4.2 +/- 10.6% for Aix. This difference was statistically significant (p < 0.01). During the euglycemic clamp, insulin improved, but did not normalize the increased values for AP and Aix in patients with type 1 diabetes. Concerning parameters of endothelial function, patients with type 1 diabetes showed statistically significant increased values for nitrotyrosine compared to healthy controls at baseline [low insulin: diabetes mellitus (DM) 1993.12 +/- 1330.85 nmol/liter vs healthy controls 803.7 +/- 726.91; high insulin DM: 2208.02 +/- 1736.57 nmol/liter vs healthy controls: 750.83 +/- 426.03 nmol/liter] (p < 0.05).

CONCLUSION

Patients with type 1 diabetes mellitus revealed an increased arterial stiffness measured as augmentation and augmentation index and increased nitrotyrosine levels as a marker of oxidative stress compared to healthy control subjects at baseline. Application of insulin improves the arterial elastic properties, but was not able to normalize the vascular function in patients with type 1 diabetes.

Strattera: ups, downs, and emerging uses

Although overall prescribing of atomoxetine hydrochloride (HCI) (Strattera) continues to decline, recent anecdotal reports suggest emerging uses of the product in combination therapy. In this article we examine trends in atomoxetine (HCI) prescribing as well as use in combination with other psychotropic classes. An expert commentary is provided on the data.

Increased arterial augmentation and augmentation index as surrogate parameters for arteriosclerosis in subjects with diabetes mellitus and nondiabetic subjects with cardiovascular disease

BACKGROUND

Arterial augmentation (AP) and the augmentation index (Aix) are surrogate parameters of arterial stiffness and are commonly used as predictors for cardiovascular risk. The aim of this study is to compare these parameters in diabetic subjects and nondiabetic cardiovascular risk subjects with healthy control subjects.

METHODS

One hundred sixty-six nonsmoking subjects aged between 35 and 70 years were included in the study, which included 100 subjects with cardiovascular disease but not diabetes (mean age 62.73+/-8.75 years), 33 subjects with type 2 diabetes (66.58+/-2.69 years), and 33 healthy controls (51.89+/-8.91 years). In these subjects, arterial stiffness was measured by the difference between the second and the first systolic peak of the central pressure waveform, and the Aix was calculated as the percentage of Aix from pulse pressure.

RESULTS

Arterial augmentation was increased in subjects with diabetes (DM) with 10.21+/-6.97 mm Hg and in subjects with cardiovascular disease but not diabetes (CV) with 10.74+/-5.29 mm Hg in comparison to healthy controls (C) with 6.59+/-3.97 mm Hg (p < 0.0005 DM vs C; p < 0.00005 CV vs C). Moreover, Aix was increased with 26.00+/-9.91% in CV subjects compared to healthy controls with 19.84+/-9.37% (p < 0.02 CV vs C). The augmentation index was increased with 21.12+/-11.21% in subjects with type 2 diabetes mellitus compared to controls, but failed to be statistically significant. There was no statistical significance in arterial augmentation or the augmentation index between CV and diabetic subjects.

CONCLUSION

The results of our study revealed a comparable increased augmentation index as a surrogate measure of arterial stiffness and arteriosclerosis in subjects with diabetes mellitus and in nondiabetic subjects with cardiovascular disease.

An Evidence-Based Approach to Augmentation and Combination Strategies for: Treatment-Resistant Depression

DESIGN, SETTING, PARTICIPANTS

This paper is a review article that collects and synthesizes up-to-date information about the practice of augmenting and combining medications in regards to treatment resistant major depressive disorder. The authors have written the paper in an evidence-based model in order to show the reader where adequate data exists in regards to these strategies. A thorough MEDLINE search was utilized to collect many papers dedicated to this area of study spanning 1989-2005.

MEASUREMENTS

Papers were divided based upon drug intervention and scientific merit, where randomized controlled trials were given the most evidence-based weight and case studies the least.

RESULTS

The literature review data is divided into augmentation and combination strategies in descending order of scientific stringency. For augmentation, lithium, antipsychotic, and thyroid addition has the most empirical support. For combination strategies, heterocyclic addition is the best studied.

CONCLUSION

There is much literature regarding complex medication management of major depression that is generally supportive of this practice. However, much of the literature contains underpowered and uncontrolled studies.

Combination/augmentation strategies for improving the treatment of depression

Depression is a common and debilitating condition, with considerable impact for depressed individuals and a heavy burden for society. In spite of its prevalence, depression is underrecognized and under- or inappropriately treated. In spite of the large number of antidepressants available at the present time, they are far from ideal and all show a similar slow, and frequently, incomplete response. Thus, the need for new and better compounds is as urgent and compelling as ever. While waiting for the panacea of future antidepressants, clinicians have developed a variety of associations of several antidepressants or an antidepressant with a second different agent. This article reviews the various strategies adopted by clinicians in the hope of increasing the response rate of current antidepressants to obtain full remission and/or to overcome treatment-resistant depression.

The Drosophila metabotropic glutamate receptor DmGluRA regulates activity-dependent synaptic facilitation and fine synaptic morphology

In vertebrates, several groups of metabotropic glutamate receptors (mGluRs) are known to modulate synaptic properties. In contrast, the Drosophila genome encodes a single functional mGluR (DmGluRA), an ortholog of vertebrate group II mGluRs, greatly expediting the functional characterization of mGluR-mediated signaling in the nervous system. We show here that DmGluRA is expressed at the glutamatergic neuromuscular junction (NMJ), localized in periactive zones of presynaptic boutons but excluded from active sites. Null DmGluRA mutants are completely viable, and all of the basal NMJ synaptic transmission properties are normal. In contrast, DmGluRA mutants display approximately a threefold increase in synaptic facilitation during short stimulus trains. Prolonged stimulus trains result in very strongly increased ( approximately 10-fold) augmentation, including the appearance of asynchronous, bursting excitatory currents never observed in wild type. Both defects are rescued by expression of DmGluRA only in the neurons, indicating a specific presynaptic requirement. These phenotypes are reminiscent of hyperexcitable mutants, suggesting a role of DmGluRA signaling in the regulation of presynaptic excitability properties. The mutant phenotypes could not be replicated by acute application of mGluR antagonists, suggesting that DmGluRA regulates the development of presynaptic properties rather than directly controlling short-term modulation. DmGluRA mutants also display mild defects in NMJ architecture: a decreased number of synaptic boutons accompanied by an increase in mean bouton size. These morphological changes bidirectionally correlate with DmGluRA levels in the presynaptic terminal. These data reveal the following two roles for DmGluRA in presynaptic mechanisms: (1) modulation of presynaptic excitability properties important for the control of activity-dependent neurotransmitter release and (2) modulation of synaptic architecture.

Vertebroplasty in the treatment of vertebral tumors: postprocedural outcome and quality of life

The results of percutaneous vertebroplasty with polymethylmethacrylate (PMMA) of vertebral metastases were evaluated by a retrospective review of a consecutive series of 21 patients, with special reference to functional outcome. Patients complained of vertebral pain in all cases. Walking was impossible for 13 patients. Ten patients presented neurological deficit. Treatment included percutaneous vertebroplasty in all patients, radiotherapy in 15 patients and neural decompression surgery in 3 patients. Mean duration of hospitalization was 14.1 days (range 2-60 days) and the mean follow-up was 5.6 months (range 1-18 months). Preprocedural pain, measured by the visual analog scale (VAS), was 9.1, decreasing to 3.2 after the procedure and 2.8 at the last follow-up visit. Morphinics were discontinued in 7 of 14 patients following discharge from hospital. Ten out of 13 (77%) patients recovered walking capacity. Neurological status improved in three out of five patients. No further vertebral compression occurred in the vertebrae treated. Overall, 81% of the patients in this study were satisfied or very satisfied with the procedure. One patient (5%) had transitory radicular neuritis after the procedure. No major complications were observed. In conclusion, percutaneous vertebroplasty with PMMA proved to be safe and beneficial, providing significant and early improvement in the functional status of patients with spinal metastasis.

Stage of breast cancer at diagnosis among women with cosmetic breast implants

Concern has been raised about the potential delay in breast cancer diagnosis in the augmented breast. We linked a cohort of 2955 women, who received cosmetic breast implants in Denmark during the period 1973-1997 with the Danish Cancer Registry and the Danish Breast Cancer Cooperative Group register. We identified 23 incident cases of invasive breast cancer diagnosed subsequent to breast implantation. We randomly selected 11 controls for each case from the Danish Breast Cancer Cooperative Group's register, and obtained detailed information on all study subjects about surgery, histopathology and stage of breast cancer at diagnosis, intended adjuvant treatment according to trial protocols and overall survival. We found that women with breast implants on average were diagnosed with breast cancer at the same stage as controls. Significantly more women with breast implants had tumour cells in the surgical margins according to the Danish Breast Cancer Cooperative Group's data. There was no significant difference in overall survival between the two groups after an average of 6.4 years of follow-up. Based on this limited number of women with breast cancer subsequent to breast augmentation, breast implants do not appear to delay the diagnosis of breast cancer, and no evidence of impaired survival after breast cancer diagnosis in augmented women was found.

Percutaneous transpedicular vertebroplasty with PMMA: operative technique and early results. A prospective study for the treatment of osteoporotic compression fractures

Vertebroplasty-percutaneous cement augmentation of osteoporotic vertebrae is an efficient procedure for the treatment of painful vertebral fractures. From a prospectively monitored series of 70 patients with 193 augmented vertebrae for osteoporotic and metastatic lesions, we analysed a group of 17 patients suffering from back pain due to osteoporotic fractures. The reinforcement of 45 vertebral bodies in these patients led to a significant and lasting pain reduction (P < 0.01 ). The presented technique is useful, as, in one session, at least four injections can be performed when required, allowing the prophylactic reinforcement of adjacent vertebrae as well. The use of a low-viscosity polymethyl methacrylate (PMMA) in combination with a non-ionic liquid contrast dye provides a reliable and safe procedure. Extraosseous cement leakage was seen in 20% of the interventions; however, none of them had clinical sequelae.

Role of inspiratory pacemaker neurons in mediating the hypoxic response of the respiratory network in vitro

In severe hypoxia the breathing frequency is modulated in a biphasic manner: an initial increase (augmentation) is followed by a depression and cessation of breathing (apnea). Using a mouse slice preparation that contains the functional respiratory network, we aimed at identifying the neurons responsible for this frequency modulation. Whole-cell patch recordings revealed that expiratory neurons become tonically active during anoxia, indicating that these neurons cannot be responsible for the respiratory frequency modulation. Inspiratory neurons tended to depolarize (by 6.9 mV; n = 9), and the frequency of rhythmic activity was significantly increased during anoxia (from 0.16 to 0.4 Hz; n = 9). After the blockade of network activity with 6-cyano-7-nitroquinoxaline-2, 3-dione, most inspiratory neurons became tonically active (72%; n = 25, non-pacemaker). In anoxia, the membrane potential of these non-pacemaker neurons did not change (-0.26 mV; n = 6), and their tonic activity ceased. Only a subpopulation of inspiratory neurons remained rhythmically active in the absence of network activity (pacemaker neurons, 28%, 7 of 25 inspiratory neurons). In anoxia two subgroups of pacemaker neurons were differentiated; one group showed a transient increase in the bursting activity, followed by a decrease and cessation of rhythmic activity. These neurons tended to depolarize (by 10.3 mV) during anoxia. The second group remained rhythmic during the entire anoxic exposure and exhibited no depolarization. The time course of the frequency modulation in all pacemaker neurons resembled that of the intact network. We conclude that pacemaker neurons are primarily responsible for the frequency modulation in anoxia and that in the respiratory network there is a strict separation between rhythm- and pattern-generating mechanisms.