Macrophage- and RIP3-dependent inflammasome activation exacerbates retinal detachment-induced photoreceptor cell death

Detachment of photoreceptors from the retinal pigment epithelium is seen in various retinal disorders, resulting in photoreceptor death and subsequent vision loss. Cell death results in the release of endogenous molecules that activate molecular platforms containing caspase-1, termed inflammasomes. Inflammasome activation in retinal diseases has been reported in some cases to be protective and in others to be detrimental, causing neuronal cell death. Moreover, the cellular source of inflammasomes in retinal disorders is not clear. Here, we demonstrate that patients with photoreceptor injury by retinal detachment (RD) have increased levels of cleaved IL-1β, an end product of inflammasome activation. In an animal model of RD, photoreceptor cell death led to activation of endogenous inflammasomes, and this activation was diminished by Rip3 deletion. The major source of Il1b expression was found to be infiltrating macrophages in the subretinal space, rather than dying photoreceptors. Inflammasome inhibition attenuated photoreceptor death after RD. Our data implicate the infiltrating macrophages as a source of damaging inflammasomes after photoreceptor detachment in a RIP3-dependent manner and suggest a novel therapeutic target for treatment of retinal diseases.

Mammalian STE20-like kinase 2, not kinase 1, mediates photoreceptor cell death during retinal detachment

Photoreceptor cell death is the definitive cause of vision loss in retinal detachment (RD). Mammalian STE20-like kinase (MST) is a master regulator of both cell death and proliferation and a critical factor in development and tumorigenesis. However, to date the role of MST in neurodegeneration has not been fully explored. Utilizing MST1^−/− and MST2^−/− mice we identified MST2, but not MST1, as a regulator of photoreceptor cell death in a mouse model of RD. MST2^−/− mice demonstrated significantly decreased photoreceptor cell death and outer nuclear layer (ONL) thinning after RD. Additionally, caspase-3 activation was attenuated in MST2^−/− mice compared to control mice after RD. The transcription of p53 upregulated modulator of apoptosis (PUMA) and Fas was also reduced in MST2^−/− mice post-RD. Retinas of MST2^−/− mice displayed suppressed nuclear relocalization of phosphorylated YAP after RD. Consistent with the reduction of photoreceptor cell death, MST2^−/− mice showed decreased levels of proinflammatory cytokines such as monocyte chemoattractant protein 1 and interleukin 6 as well as attenuated inflammatory CD11b cell infiltration during the early phase of RD. These results identify MST2, not MST1, as a critical regulator of caspase-mediated photoreceptor cell death in the detached retina and indicate its potential as a future neuroprotection target.

Programmed necrosis, not apoptosis, is a key mediator of cell loss and DAMP-mediated inflammation in dsRNA-induced retinal degeneration

There is no known treatment for the dry form of an age-related macular degeneration (AMD). Cell death and inflammation are important biological processes thought to have central role in AMD. Here we show that receptor-interacting protein (RIP) kinase mediates necrosis and enhances inflammation in a mouse model of retinal degeneration induced by dsRNA, a component of drusen in AMD. In contrast to photoreceptor-induced apoptosis, subretinal injection of the dsRNA analog poly(I : C) caused necrosis of the retinal pigment epithelium (RPE), as well as macrophage infiltration into the outer retinas. In Rip3(-/-) mice, both necrosis and inflammation were prevented, providing substantial protection against poly(I : C)-induced retinal degeneration. Moreover, after poly(I : C) injection, Rip3(-/-) mice displayed decreased levels of pro-inflammatory cytokines (such as TNF-α and IL-6) in the retina, and attenuated intravitreal release of high-mobility group box-1 (HMGB1), a major damage-associated molecular pattern (DAMP). In vitro, poly(I : C)-induced necrosis were inhibited in Rip3-deficient RPE cells, which in turn suppressed HMGB1 release and dampened TNF-α and IL-6 induction evoked by necrotic supernatants. On the other hand, Rip3 deficiency did not modulate directly TNF-α and IL-6 production after poly(I : C) stimulation in RPE cells or macrophages. Therefore, programmed necrosis is crucial in dsRNA-induced retinal degeneration and may promote inflammation by regulating the release of intracellular DAMPs, suggesting novel therapeutic targets for diseases such as AMD.

A psychopharmacological treatment algorithm for generalised anxiety disorder (GAD)

Generalised anxiety disorder (GAD) is defined as excessive and uncontrollable worry and anxiety about everyday life situations. It is a chronic disorder, and is associated with substantial somatisation, high rates of comorbid depression and other anxiety disorders, and significant disability. The evidence base for pharmacotherapy and psychotherapy has continued to grow, and a wide range of drug choices for GAD now exists. Current guidelines for GAD generally restrict themselves to presentation of the evidence for various treatments, which, as a result, generally do not offer detailed discussion or recommendation of strategies beyond the first level of treatment, or take into account the individual circumstances of the patient. Thus, there is a lack of algorithm-based treatment guidelines for GAD. Our aim is, therefore, to present an algorithm for the psychopharmacologic management of GAD, intended for all clinicians who treat patients with GAD, where issues of pharmacotherapy are under consideration. We also hope that these GAD algorithms and other guidelines can help to identify high-priority areas that need further study. In this algorithm, we provide a sequenced approach to the pharmacotherapy of GAD, taking into account salient symptomatology and comorbidity, levels of evidence and extent of response. Special issues, including comorbidity, insomnia, suicidality, substance abuse, treatment adherence, pregnancy and lactation, cross-cultural issues, use of medication in the elderly, psychosocial treatment and dosing issues are also addressed.

Computer-aided quantification of retinal neovascularization

Rodent models of retinal angiogenesis play a pivotal role in angiogenesis research. These models are a window to developmental angiogenesis, to pathological retinopathy, and are also in vivo tools for anti-angiogenic drug screening in cancer and ophthalmic research. The mouse model of oxygen-induced retinopathy (OIR) has emerged as one of the leading in vivo models for these purposes. Many of the animal studies that laid the foundation for the recent breakthrough of anti-angiogenic treatments into clinical practice were performed in the OIR model. However, readouts from the OIR model have been time-consuming and can vary depending on user experience. Here, we present a computer-aided quantification method that is characterized by (i) significantly improved efficiency, (ii) high correlation with the established hand-measurement protocols, and (iii) high intra- and inter-individual reproducibility of results. This method greatly facilitates quantification of retinal angiogenesis while at the same time increasing lab-to-lab reproducibility of one of the most widely used in vivo models in angiogenesis research.

Randomized, controlled trial of telcagepant for the acute treatment of migraine

BACKGROUND

The neuropeptide calcitonin gene-related peptide (CGRP) plays a key role in migraine pathophysiology. In this large phase 3 clinical trial, we sought to confirm the efficacy of telcagepant, the first orally bioavailable CGRP receptor antagonist.

METHODS

Adults with migraine with or without aura (International Headache Society criteria) treated a moderate or severe attack with oral telcagepant 50 mg (n = 177), 150 mg (n = 381), 300 mg (n = 371), or placebo (n = 365) in a randomized, double-blind trial. The 5 co-primary endpoints were pain freedom, pain relief, and absence of photophobia, absence of phonophobia, and absence of nausea, all at 2 hours postdose. The key secondary endpoint was 2-24 hour sustained pain freedom. The prespecified primary efficacy analyses evaluated the 150 mg and 300 mg groups; the 50-mg group was included on an exploratory basis to further characterize the dose response but was not prespecified for analysis. Tolerability was assessed by adverse experience reports.

RESULTS

Telcagepant 300 mg was more effective (p <or= 0.001) than placebo on all primary endpoints and the key secondary endpoint, as was telcagepant 150 mg (p <or= 0.05). Telcagepant 300 mg showed a slight numeric advantage over telcagepant 150 mg on most measures. Telcagepant 50 mg values were numerically intermediate between placebo and telcagepant 150 mg and 300 mg. The percentages of patients with adverse experiences were 32.2% for telcagepant 50 mg, 32.0% for telcagepant 150 mg, 36.2% for telcagepant 300 mg, and 32.2% for placebo.

CONCLUSIONS

This study confirmed previous findings that telcagepant 300 mg was effective at relieving pain and other migraine symptoms at 2 hours and providing sustained pain freedom up to 24 hours. In this study, telcagepant 150 mg was also effective. Telcagepant was generally well tolerated.

Matrigel cytometry: a novel method for quantifying angiogenesis in vivo

Many of the current in vivo methods to evaluate angiogenesis are poorly quantifiable. Recently, the Matrigel plug assay has become the method of choice in many studies involving in vivo testing for angiogenesis. When known angiogenic factors are mixed with Matrigel and injected subcutaneously into mice, endothelial cells migrate into the gel plug. These endothelial cells form vessel-like structures, a process that mimics the formation of capillary networks. Here, we present a modification of the traditional Matrigel assay with improved method to quantify the amount of endothelial cells that incorporate into the plug. The removed plugs were subjected to a mild protease treatment, yielding intact cells. The liberated cells were then stained using an endothelial cell-specific markers, and counted by flow cytometry. This novel combination of FACS analysis with the traditional Matrigel assay improves the ability to quantify in vivo angiogenesis, and for the first time enables to determine the number of migrating and proliferating endothelial cells which reflects the angiogenesis rate.

A placebo-controlled study of Kava kava in generalized anxiety disorder

We assessed the efficacy and safety of a botanical anxiolytic, Kava kava (Piper methysticum), in treating generalized anxiety disorder (GAD). Thirty-seven adults with DSM-IV GAD were randomly assigned to 4 weeks of double-blind treatment with kava or a matching placebo. Weekly efficacy assessments [Hamilton Anxiety Scale, Hospital Anxiety and Depression Scale (HADS), Self Assessment of Resilience and Anxiety (SARA)] and safety evaluations were conducted. Improvement was observed with both treatments but no differences were found in the principal analysis. Post-hoc analyses revealed significant differences based on baseline anxiety severity, whereby kava was superior on the SARA in low anxiety and placebo was superior on the HADS and SARA in high anxiety. Both treatments were well tolerated. Although kava was not superior to placebo, it would be premature to rule it out as efficacious in GAD.

Panic disorder and social phobia: current treatments and new strategies

Panic disorder and social phobia are among the most disabling of the anxiety disorders. The emotional cost to the patient suffering from these diagnoses is exceeded only by the very real economic costs to the community because of reduced productivity, lost workdays, and increased health care costs for associated physical complaints. It is imperative, therefore, that the medical community focus on the accurate diagnosis and effective treatment of these potentially devastating conditions. Pharmacologic treatments for panic disorder and social phobia have been available since the early 1960s. The limited efficacy and significant side effects of the early medications, however, led to a search for new treatment options. For many years, the benzodiazepines were the principal first-line therapy for treatment of these illnesses. Yet, their potential for cognitive impairment, physiological dependence, abuse, and withdrawal phenomena warranted a continued search for newer agents with an improved safety profile. In the last 10 years, several treatments have been identified that may fill this need. Controlled trials and/or anecdotal reports have shown SSRIs and anticonvulsants to be effective treatments for the symptoms of panic disorder and social phobia. However, although SSRIs are emerging as a leading treatment for generalized social phobia, it is not at all clear whether they can benefit nongeneralized social phobia. Their side-effect profile, while a marked improvement over earlier antidepressant drugs, still can cause significant discomfort. The anticonvulsants are now emerging as a very important group of drugs in the anxiety disorders, with gabapentin having been the most extensively studied in social phobia.

Mini-SPIN: A brief screening assessment for generalized social anxiety disorder

The objectives of this study are to develop a brief self-rated screening instrument for generalized social anxiety disorder (GSAD) and to test the efficiency of the instrument. The Social Phobia Inventory (SPIN), a 17-item self-administered scale for GSAD, was given to 263 individuals with GSAD and controls. A subset of three items yielding high sensitivity and specificity for the diagnosis of GSAD was identified. This abbreviated version of the SPIN (Mini-SPIN) was administered to a group of managed care patients in conjunction with an epidemiological study of GSAD. Patients (n = 7,165) were sent a questionnaire comprising the Mini-SPIN and a brief depression screener. Respondents screening positive for GSAD on the Mini-SPIN (n = 344) were interviewed using the social phobia module of the Structured Clinical Interview for DSM-IV (SCID) to verify the diagnosis. A random sample of those who screened negative for GSAD on the Mini-SPIN were administered a similar interview to identify two control groups without GSAD for comparison (n = 673). With this information, the sensitivity, specificity, and positive and negative predictive values for the Mini-SPIN were determined (weighted for sampling). Using a cutoff score of 6 or greater, the Mini-SPIN demonstrated a sensitivity of 88.7%, specificity of 90.0%, positive predictive value of 52.5%, and negative predictive value of 98.5%. The scale possessed 90% accuracy (efficiency) in diagnosing the presence or absence of GSAD in a managed care population. The Mini-SPIN demonstrates good efficiency, supporting its utility as a screening tool for generalized social anxiety disorder.

Effect of kava extract on vagal cardiac control in generalized anxiety disorder: preliminary findings

Anxiety disorders are associated with low vagal control of heart rate and increased risk of cardiac mortality and sudden cardiac death. This study examined whether the herbal anxiolytic, kava, produces improvement in vagal control in generalized anxiety disorder. Before and after treatment with placebo (n = 7) or kava (n = 6), two indices of vagal control were measured under supine conditions using power spectral analysis: baroreflex control of heart rate (BRC) and respiratory sinus arrhythmia (RSA). Significantly more patients treated with kava showed improved BRC compared to the placebo group (p < 0.05). Furthermore, the magnitude of improvement in BRC was significantly correlated with the degree of clinical improvement (p < 0.05). RSA did not respond to treatment. These preliminary findings suggest that kava might exert a favourable effect on reflex vagal control of heart rate in generalized anxiety disorder patients. The parallel clinical and BRC responses may reflect an underlying common effect of this herbal anxiolytic.

Adverse-effect profile of kava

The use of alternative therapies has increased substantially over the last decade, particularly for more chronic conditions such as anxiety. Among the most widely used treatments are medicinal herbs, or phytomedicines, such as kava (Piper methysticum), which has demonstrated anxiolytic activity in both animal models and clinical samples. Kava has several advantages over conventional pharmacologic treatments for anxiety--in clinical settings it has been associated with better tolerability and lack of physiologic dependence and withdrawal. However, phytomedicines are not rigorously regulated in the United States and systematically collected safety data are very limited. These issues are a leading concern regarding the safety of medicinal herbs such as kava. In this report, the safety profile for kava is provided, including findings from a study of its use in generalized anxiety disorder. Safety parameters assessed include occurrence of adverse events, withdrawal symptoms, effect on heart rate, blood pressure, laboratory assessments, and sexual function. No differences were found between kava and placebo on any of the parameters evaluated. The data support the safety of kava in treating anxiety at 280 mg kava lactones/day for 4 weeks.

The self-assessment of resilience and anxiety: psychometric properties

This report describes the psychometric properties of the Self-Assessment of Resilience and Anxiety (SARA) scale within the context of a study of kava for generalized anxiety. This eight-item, patient-rated scale includes questions designed to measure calmness, mental clarity, confidence, physical well being, sociability, and resilience. The SARA scale was administered during a clinical trial of kava versus placebo in 38 subjects diagnosed with generalized anxiety disorder (GAD). Validation of the SARA scale was assessed against the Hamilton Rating Scale for Anxiety, Hospital Anxiety and Depression Scale, Penn State Worry Questionnaire, Sheehan Disability Scale, Arizona Sexual Experience scale, and Clinical Global Impression of Illness Improvement scale. Good test-retest reliability, internal consistency, convergent validity, and sensitivity to treatment were identified, and factor analyses revealed a three-factor internal structure. The SARA scale was responsive to symptom change over time and correlated with comparable GAD symptom measures. The SARA scale demonstrates solid psychometric properties and may serve as a reliable and valid measure in the use of kava or related medicinal herbs.

SPRINT: a brief global assessment of post-traumatic stress disorder

This report describes the reliability, validity, treatment sensitivity, diagnostic performance and normative values for the Short Post-Traumatic Stress Disorder (PTSD) Rating Interview (SPRINT), a brief, global assessment for PTSD. The SPRINT was administered to subjects participating in a clinical trial of PTSD and in a population survey assessing PTSD prevalence. The 8-item SPRINT includes questions assessing the core symptoms of PTSD, as well as related aspects of somatic malaise, stress vulnerability and functional impairment. Validity was assessed against the MINI structured interview, the Davidson Trauma Scale, Treatment Outcome for PTSD Scale, Connor-Davidson Resilience Scale, Sheehan Stress Vulnerability Scale, Sheehan Disability Scale and Clinical Global Impressions of Severity and Improvement Scales. Good test-retest reliability, internal consistency, convergent and divergent validity were obtained. The SPRINT was responsive to symptom change over time and correlated with comparable PTSD symptom measures. In victims of trauma, a score of 14-17 was associated with 96% diagnostic accuracy, whereas in those with PTSD, highest efficiency corresponded to a range of 11-13. The SPRINT demonstrates solid psychometric properties and can serve as a reliable, valid and homogeneous measure of PTSD illness severity and of global improvement.

Olanzapine in the treatment of post-traumatic stress disorder: a pilot study

Because the atypical antipsychotic olanzapine may be efficacious in treating post-traumatic stress disorder (PTSD) symptoms, we conducted a 10-week, double-blind, placebo-controlled evaluation in which 15 patients were randomized 2:1 to either olanzapine or placebo. The initial dosage was 5 mg/day and was titrated to a maximum of 20 mg/day. Eleven patients completed the study. Patients in both groups showed improvement in PTSD symptoms, but no between-group differences in treatment response were observed and a high placebo response rate was found. Both treatments were tolerated well, although the olanzapine treatment group had more weight gain. Olanzapine fared no better than placebo in this preliminary study in the treatment of PTSD. The lack of difference between olanzapine and placebo may in part be due to olanzapine's not being effective in PTSD or, alternatively, a small sample size, a high placebo response in certain forms of PTSD and the chronicity of PTSD symptoms in some patients.

Predictors of treatment response in patients with posttraumatic stress disorder

1. This study examines the relation between baseline clinical characteristics in patients with posttraumatic stress disorder (PTSD) and response to treatment with a reversible monoamine oxidase A inhibitor (RIMA), brofaromine. 2. Data from two comparable, double-blind, placebo-controlled studies of brofaromine in patients with PTSD were combined. Bivariate analyses of variables of interest and outcome were performed. 3. Treatment response was significantly associated with lower baseline scores on the full scale Clinician-Administered PTSD Scale (CAPS) and on CAPS subscales B (re-experiencing) and C (avoidance/numbing), as well as to drug treatment with brofaromine. Placebo response was related to a history of past sexual trauma. 4. Brofaromine may have therapeutic benefit in treating PTSD, with lower baseline levels of reexperiencing and avoidance/numbing and overall less severe PTSD most predictive of outcome.

Further psychometric assessment of the TOP-8: a brief interview-based measure of PTSD

The TOP-8 scale was developed as a brief, clinician-administered scale for use in assessing responses to treatment in patients with post-traumatic stress disorder. Further psychometric evaluation of the scale has now been undertaken and is reported and discussed here.

Characterization of United Kingdom isolates of Corynebacterium pseudotuberculosis using pulsed-field gel electrophoresis

Caseous lymphadenitis is a chronic suppurative disease caused by Corynebacterium pseudotuberculosis and is responsible for serious economic losses to the sheep and goat industry. Caseous lymphadenitis was first reported for goats in the United Kingdom in 1990 and for sheep in 1991. Recent evidence suggests that the prevalence of the disease within the national flock is increasing. Fifty isolates of C. pseudotuberculosis from the United Kingdom comprising sheep and horse isolates, the original goat outbreak strain, and the type strain were characterized by biotyping, antimicrobial susceptibility, production of phospholipase D, and genotyping by pulsed-field gel electrophoresis using SfiI and SmaI. All of the isolates were confirmed as C. pseudotuberculosis, and all produced phospholipase D but none reduced nitrate. Restriction with SfiI generated 16 to 18 bands between 48.5 and 290 kb and differentiated six pulsotypes. We conclude that 80% of the strains tested were epidemiologically related to the outbreak strain and that the equine profile was distinct both phenotypically and genotypically.

Symptom-specific effects of fluoxetine in post-traumatic stress disorder

The selective serotonin reuptake inhibitors have become a first line treatment for post-traumatic stress disorder (PTSD). In a recent double-blind study in civilians, fluoxetine produced clinically and statistically significant effects on all general measures of PTSD. We examined the specific effects of fluoxetine versus placebo in the above mentioned study of PTSD clusters and individual symptoms. Individuals were included if they met criteria for PTSD according to the Structured Clinical Interview for DSM-III-R (SCID). Symptoms were assessed at sequential time points by the Structured Interview for PTSD (SIP), a clinician interview based assessment, and a self-report scale, the Davidson Trauma Scale (DTS). A total of 53 patients were included in the analysis. On the SIP and DTS, fluoxetine was found to produce statistically significant changes on all clusters. Significant effects for fluoxetine were noted on 10 items of the DTS, and 8 items of the SIP. The SIP and DTS had 6 items in common that were significant. Fluoxetine exerts a broad spectrum effect in reducing all the symptom clusters of PTSD in this sample. The symptoms of being physically upset at reminders of the trauma, avoiding thoughts of the trauma, having difficulty enjoying things, feeling distant/estranged, having a sense of foreshortened future, and impaired concentration, were the symptoms most responsive to the effects of treatment with fluoxetine on both scales.

ECT stimulus intensity: are present ECT devices too limited?

OBJECTIVE

The maximum output charge for ECT devices is limited to 576 millicoulombs in the United States, although there are no data ensuring that this limit will allow consistently effective treatments. The authors examined whether this limit has a negative impact on therapeutic response and, therefore, whether a higher stimulus charge should be available.

METHOD

They retrospectively reviewed the records of 471 patients who received a clinical index course of ECT at Duke University between 1991 and 1998. These patients received conservative stimulus dosing of 2.25 times seizure threshold for unilateral ECT and 1.5 times seizure threshold for bilateral ECT.

RESULTS

Seventy-two (15%) of the 471 patients required the maximum stimulus intensity during their index ECT course. Of these, 24 (5% of the total) had either a short EEG seizure (less than 25 seconds) or had no seizure at the maximum level. Strategies to augment therapeutic response with caffeine, ketamine, or hyperventilation were used in 14 of the 24 patients, and data on therapeutic response were available for 22 of the 24. Only seven (32%) of these 22 patients were considered ECT responders, compared with 242 (66%) of the remaining 364 patients for whom data on response to ECT were available. Older age and pre-ECT course EEG slowing were predictors of requiring the maximum stimulus level.

CONCLUSIONS

The maximum available stimulus output was therapeutically insufficient for 5% of the patients studied even when available means to augment response were instituted. This percentage would likely be even larger with the use of a less conservative dosing protocol for unilateral ECT. Increases in maximum stimulus output for ECT devices should be considered as a means to ensure adequate treatment response.

Psychometric properties of the Social Phobia Inventory (SPIN). New self-rating scale

BACKGROUND

Of available self-rated social phobia scales, none assesses the spectrum of fear, avoidance, and physiological symptoms, all of which are clinically important. Because of this limitation, we developed the Social Phobia Inventory (SPIN).

AIMS

To establish psychometric validation of the SPIN.

METHOD

Subjects from three clinical trials and two control groups were given the 17-item, self-rated SPIN. Validity was assessed against several established measures of social anxiety, global assessments of severity and improvement, and scales assessing physical health and disability.

RESULTS

Good test-retest reliability, internal consistency, convergent and divergent validity were obtained. A SPIN score of 19 distinguished between social phobia subjects and controls. The SPIN was responsive to change in symptoms over time and reflected different responses to active drugs v. placebo. Factorial analysis identified five factors.

CONCLUSIONS

The SPIN demonstrates solid psychometric properties and shows promise as a measurement for the screening of, and treatment response to, social phobia.

Social phobia: issues in assessment and management

Social phobia was initially classified with phobic anxiety states and was believed to be quite rare, but it is now gaining due recognition as a widespread and often crippling disorder. The boundaries of social phobia merge into traits of shyness and universal performance anxiety, with symptoms commonly appearing in the teenage years. If left untreated, social phobia is a remarkably persistent condition, leading to potentially lifelong impairment in social development and occupational functioning. It may also give rise to other co-morbid disorders, particularly dysthymia, depression, obsessive-compulsive disorder, other phobic disorders, and substance abuse. Over the years, social phobia has been all too frequently viewed as a somewhat trivial, minor form of psychiatric illness and has received little clinical attention. This erroneous perception is now giving way under the mounting evidence in support of the extensive morbidity and disability associated with social phobia and the probable role of genetic and environmental influences. Furthermore, data from multiple controlled clinical trials reveal that this is a treatable condition, responding to both psychosocial and pharmacologic interventions. Here we examine issues to consider in the differential diagnosis of social phobia, review the goals of treatment, and summarize evidence in support of the effectiveness of individual pharmacologic treatments.

Management of posttraumatic stress disorder: diagnostic and therapeutic issues

Although the hallmark symptoms of posttraumatic stress disorder (PTSD) are clear, this disorder is not always properly diagnosed. Reasons for misdiagnosis include a high rate of comorbidity, patient denial or minimization, overly high diagnostic thresholds set by clinicians, or failure to take a trauma history. There are a number of challenges associated with the treatment of PTSD. Patients with PTSD may not respond to pharmacotherapy in the same manner, and it is unclear whether this is related to gender, trauma type, or other factors. Antidepressants, particularly the selective serotonin reuptake inhibitors, are the most effective form of pharmacotherapy for patients with PTSD. Patients also may respond to therapy with monoamine oxidase inhibitors or tricyclic antidepressants. Psychosocial techniques, such as cognitive-behavioral therapy or stress inoculation training, are effective and may be considered as adjunctive therapy with medication. As awareness of PTSD increases, more patients should receive an accurate diagnosis and appropriate therapy.

Fluoxetine in post-traumatic stress disorder. Randomised, double-blind study

BACKGROUND

Most pharmacotherapy trials in post-traumatic stress disorder (PTSD) have been conducted upon male combat veterans. Outcome studies relating to civilians are therefore needed.

AIMS

To demonstrate that fluoxetine is more effective than placebo in treating PTSD.

METHOD

Civilians with PTSD (n = 53) were treated for 12 weeks with fluoxetine (up to 60 mg/day) or placebo. Assessments of PTSD severity, disability, stress vulnerability, and high end-state function were obtained.

RESULTS

Fluoxetine was more effective than placebo on most measures at week 12, including global improvement (much or very much improved: fluoxetine 85%, placebo 62%, difference 0.24, 95% CI 0.01-0.47; very much improved: fluoxetine 59%, placebo 19%, difference 0.40, 95% CI 0.16-0.64), and high end-state function (fluoxetine 41%, placebo 4%, difference 0.37, 95% CI 0.17-0.57).

CONCLUSIONS

Fluoxetine was superior for measures of PTSD severity, disability, stress vulnerability, and high end-state function. The placebo-group response was low when viewed as a broad outcome based on a portfolio of ratings, but was higher with a traditional global rating criterion.

A preliminary study of lamotrigine for the treatment of posttraumatic stress disorder

BACKGROUND

The anticonvulsant, lamotrigine, may be useful for symptom management in PTSD.

METHODS

Subjects enrolled in a 12-week double-blind evaluation of lamotrigine and placebo. Patients were randomized 2:1 to either lamotrigine or placebo. Lamotrigine was initiated at 25 mg/day and slowly titrated every 1 to 2 weeks over 8 weeks to a maximum dosage of 500 mg/day if tolerated.

RESULTS

Fifteen subjects entered treatment, fourteen of whom returned for subsequent visits. Of 10 patients who received lamotrigine, 5 (50%) responded according to the DGRP, compared to 1 of 4 (25%) who received placebo. Lamotrigine patients showed improvement on reexperiencing and avoidance/numbing symptoms compared to placebo patients. Treatments were generally well tolerated.

CONCLUSIONS

Lamotrigine may be effective as a primary psychopharmacologic treatment in both combat and civilian PTSD and could also be considered as an adjunct to antidepressant therapy used in the treatment of PTSD. These promising results warrant further large sample double-blind, placebo-controlled trials.

Quality of life and posttraumatic stress disorder: a pilot study assessing changes in SF-36 scores before and after treatment in a placebo-controlled trial of fluoxetine

In this small pilot study, we evaluated quality of life for 16 posttraumatic stress disorder (PTSD) patients by administering the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) at baseline and endpoint during a 12-week double-blind trial of fluoxetine and placebo. At baseline, our subjects reported greater impairment relative to subjects with major depression or obsessive-compulsive disorder on several SF-36 domains. Significant effects of fluoxetine relative to placebo were observed for vitality, social functioning, and mental health. Overall, PTSD was associated with greatly reduced quality of life, but considerable improvement was achieved through treatment.

A pilot study of mirtazapine in post-traumatic stress disorder

Recently, studies of pharmacotherapy for post-traumatic stress disorder (PTSD) have been focused on serotonin-selective reuptake inhibitors (SSRI), despite a number of treatment-limiting side-effects. Mirtazapine, a novel drug with both noradrenergic and serotonergic properties, may be effective in individuals who demonstrate intolerance to side-effects of and a limited response to SSRIs. Six outpatients with severe, chronic PTSD were treated with mirtazapine, up to 45 mg/day for 8 weeks. Efficacy assessments and side-effect monitoring were performed at baseline and weeks 2, 4, 6 and 8. Fifty percent of the sample demonstrated improvement of 50% or more from baseline using a global rating. In addition, improvements were noted on both interviewer-administered and self-rated scales of PTSD and of depression. The drug was well tolerated with few significant side-effects. Mirtazapine was associated with clinical improvement in 50% of subjects with severe, chronic PTSD, suggesting a need for further investigation in double-blind, placebo-controlled trials.

Generalized anxiety disorder: neurobiological and pharmacotherapeutic perspectives

The concept of generalized anxiety has evolved over many years, from initial descriptions of "anxiety neurosis" to recognition of generalized anxiety disorder (GAD) as a clinical entity included in the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. Since 1980, the definition of GAD has undergone further change, with modifications in the salience of autonomic and panic like symptoms, duration, and allowance of comorbidity. The importance of these historical considerations lies in the fact that most of our current knowledge about GAD rests on outdated definitions, including most of the literature pertaining to treatment. Indeed, we cannot be sure that the DSM-III definition of GAD bears resemblance to the current concept, and these differences may have profound implications for findings from research. The following two-part report comprises i) a review of the basic neurobiology of GAD, with reference to serotonergic, noradrenergic, neuroendocrine, autonomic imaging, and other systems; and ii) an overview of the current status of pharmacotherapy for GAD.

Discontinuation of clonazepam in the treatment of social phobia

Patients with social phobia who responded well to 6 months of open-label treatment with clonazepam were assigned to receive either continuation treatment (CT) with clonazepam for another 5 months, or to undergo discontinuation treatment (DT) using a clonazepam taper at the rate of 0.25 mg every 2 weeks, with double-blind placebo substitution. Clinical efficacy was compared between the CT and DT groups using three different social phobia scales. Benzodiazepine withdrawal symptoms were also measured. Relapse rates were 0 and 21.1% in the CT and DT groups, respectively. Subjects in the CT group generally showed a more favorable clinical response at midpoint and/or endpoint, although even in the DT group clinical response remained good. With respect to withdrawal symptoms, the rates were low in both groups (12.5% for CT and 27.7% for DT) with no real evidence suggesting significant withdrawal difficulties. At the end of 11 months of treatment with clonazepam, however, a more rapid withdrawal rate was associated with greater distress. This study offers preliminary evidence to suggest that continuation therapy with clonazepam in the treatment of social phobia is safe and effective, producing a somewhat greater clinical benefit than a slow-taper discontinuation regime. However, even in the DT group, withdrawal symptoms were not found to be a major problem. The study can be taken as supportive of benefit for longterm clonazepam treatment in social phobia, as well as being compatible with a reasonably good outcome after short-term treatment and slow taper.

A family study of chronic post-traumatic stress disorder following rape trauma

There is evidence that familial factors serve as determinants of risk for post-traumatic stress disorder (PTSD), especially familial anxiety. This study investigates the relationship between chronic PTSD and family psychiatric morbidity. The sample was drawn from 81 female rape survivors with or without lifetime PTSD, 31 major depressive disorder controls, 20 anxiety disorder controls and 39 healthy controls. First-degree family members were directly interviewed (n = 285) and diagnoses assigned of major depressive, anxiety and alcohol or substance use disorder. Information was also available by family history for 639 relatives. In the directly interviewed sample, no consistently increased morbidity risk was observed for anxiety, PTSD, or alcohol/substance abuse in the rape survivor groups, but there was an increase in depression relative to the anxiety in healthy control groups. When comorbid depression in rape survivor probands was taken into account post hoc, an increased risk for depression was noted in family members of PTSD probands with depression, but not in relatives of PTSD probands without lifetime depression. Among rape survivor probands with non-comorbid PTSD, rates by history of familial anxiety and depression were negligible. In a logistic regression analysis, individual vulnerability to depression served as an independent predictor of chronic PTSD, along with specific trauma-related variables. In the family history group, results were consistent with those obtained from the directly interviewed group. Our findings clearly support the view that PTSD following rape is associated with familial vulnerability to major depression, which may thus serve as a risk factor for developing PTSD. The exact nature of this predisposition calls for further inquiry and there is a need to expand this study to include other PTSD populations. PTSD may on occasion represent a form of depression which is induced and/or modified neurobiologically and phenomenologically by extreme stress. Our findings may be a reflection of the sample composition, the current conceptualization of PTSD, or be related to study limitations.

Early immunopathological events in experimental ovine paratuberculosis

An experimental oral infection of neonatal (< 2 weeks old) lambs with a cervine isolate of Mycobacterium avium subspecies paratuberculosis (M.a. paratuberculosis), the causal agent of ruminant paratuberculosis (Johne's disease) was used to investigate bacteriological, histopathological and immunological changes during the early (up to 8 weeks) post-infection phase. In vitro culture for mycobacteria was positive in one faecal and three mesenteric lymph node (MLN) samples from the eight infected lambs. All mycobacterial isolates from MLN were identified as M.a. paratuberculosis by polymerase chain reaction (PCR). Small-to-medium sized focal granulomata were observed in jejunal (JPP) and ileal Peyer's patches (IPP) from four of the eight infected lambs. Compared with controls, JPP from all infected lambs had significantly (p < 0.05) higher proportions of CD8+ and CD2+ lymphocytes, and there were significantly (p < 0.05) fewer cells expressing B lymphocyte-associated markers in IPP and MLN. The T/B cell ratio was significantly (p < 0.05) increased in both JPP and MLN from infected lambs. The expression of a range of genes for cytokines was examined using specific reverse transcriptase PCR (RT-PCR) amplification of messenger RNA (mRNA) template isolated from MLN, JPP and IPP from both groups of animals. Densitometric analyses indicated that, in infected animals, MLN expressed significantly (p < 0.05) more mRNA for TNF-alpha: JPP had significantly increased (p < 0.05) mRNA for GM-CSF and significantly decreased (p < 0.05) mRNA for IL-4 and IFN-gamma. Infected lambs had significantly (p < 0.05) decreased titres of both circulating IgG and gut mycobacteria-associated IgG antibody. Infection was not associated with any consistent changes in lymphocyte reactivity to specific mycobacterial antigens, IFN-gamma release into supernatants from in vitro intestinal lymphocyte cultures or gut IgA antibody levels.

Treatment of posttraumatic stress disorder with nefazodone

Selective serotonin reuptake inhibitors are useful in the treatment of posttraumatic stress disorder (PTSD), but have a number of side-effects which limit their acceptability. A newer serotonergic compound, nefazodone, has a different side-effect profile, thus making it a potentially promising compound to study. Seventeen private practice patients with PTSD were treated with nefazodone up to 600 mg/day for a maximum total treatment period of 12 weeks. All subjects were civilians, and were monitored for efficacy and side-effects at weeks 1, 2, 4, 6, 8 and 12. Nefazodone was associated with statistically significant improvement in mean scores on all six rating scales used to assess change from baseline in PTSD symptoms. Additionally, statistically significant improvement from baseline were seen for the intrusive, avoidant/numbing, and hyperarousal clusters on a global PTSD scale. Early improvements in nightmares and general sleep disturbance were observed. Overall, there was a 43% response rate at endpoint, or 60% in treatment completers, by observer rating. Side-effects (assessed on the Medication Effects Scale) were generally benign. Nefazodone was associated with clinical improvement in this population, and now needs to be studied in double-blind, placebo controlled, protocols.

Bupropion sustained release: a therapeutic overview

Sustained-release bupropion (bupropion SR) represents a new form of an already known effective antidepressant drug. Its pharmacokinetics, mechanism of action, metabolism, and efficacy are reviewed. Benefit relative to placebo has been demonstrated in two large multicenter trials, with low doses (100 or 150 mg) having been shown to have therapeutic efficacy. An overview of all placebo-controlled trials of bupropion SR is given, and the differential properties of bupropion and serotonergic drugs are described. The concept of a catecholamine-indolamine spectrum is presented, along with its implications for possible differential therapeutics of selective antidepressants.

Moredun Bordetella Medium, an improved selective medium for isolation of Bordetella parapertussis

Bordetella parapertussis, previously thought to be an obligate human respiratory tract pathogen, has been isolated from sheep. Attempts to assess the prevalence of B. parapertussis in conventionally reared sheep by nasal swabbing proved futile with existing selective media because of extensive overgrowth with Mucor spp. and other nasal commensals. Moredun Bordetella Medium (MBM), which contains cycloheximide and spectinomycin at final concentrations of 0.5 mg/ml and 100 mu g/ml, respectively, was developed as an improved selective medium to isolate B. parapertussis from the nasal cavities of conventionally reared sheep. The selective ability of MBM was evaluated with 200 nasal swabs from conventionally reared sheep, and B. parapertussis was recovered from 31.5% of the samples. MBM facilitated the simple and effective isolation of B. parapertussis from ovine nasal swabs and, in successfully excluding overgrowth with other contaminants, proved superior to other test formulations evaluated and to existing conventional media.

Mutagenicity of cosmetic products containing Kathon

A variety of shampoos, conditioners, skin-care lotions, and other cosmetic products contain the biocide Kathon CG, which is a mixture of two heterocyclic isothiazolinones: methylisothiazolinone and methylchloroisothiazolinone. This mixture and the related biocide, Kathon 886, have been shown to be potent sensitizers and bacterial mutagens. Five cosmetic products that list the components of Kathon on their labels and two that do not were screened for mutagenicity with Salmonella typhimurium TA100 without S-9. Five of these products and Kathon 886 were further evaluated in TA100 without and with S-9. Kathon 886, a cosmetic product that contained Kathon, and thin layer chromatography-separated components of Kathon 886 were identified by GC/MS analysis. Three of the five products that listed Kathon were direct acting mutagens with TA100. The remaining two products were considerably more toxic than the other products and could not be evaluated for mutagenicity. The addition of S-9 reduced toxicity but did not eliminate mutagenicity. The mutagenic evaluation of Kathon 886 resulted in a dose response similar to that seen with some cosmetic products but at a 1,000-fold lower concentration, and activity was also reduced by the addition of S-9 mix. S-9 reduced activity both with and without cofactors present. Thin layer chromatography separation of the components and subsequent identification by GC/MS indicated that methylisothiazolinone was nonmutagenic while methylchloroisothiazolinone was mutagenic. Additionally, a dichlorinated compound was identified which was also mutagenic. In light of these findings and the reported skin sensitization by Kathon CG in various cosmetics, we recommend that additional testing be done to assure the safety of products containing Kathon CG.

Tactile sensory coding during development: signaling capacities of neurons in kitten dorsal column nuclei

The functional maturation of cuneate neurons was studied using reproducible tactile stimulation procedures and quantitative assessment of coding capacities in anesthetized (N2O/O2 plus barbiturate infusion) or decerebrate cats from six different age groups; neonatal (1-5 days), 10-15, 25-30, 55-63, and 83-90 days, and an adult group. Cuneate neurons were distinguished from input fibers to the nucleus on criteria of spike configuration and time course and on response profiles. Extracellular spike durations underwent a progressive shortening with age, reaching the adult range at approximately 3 mo when background activity levels also reached maturity. Despite an increase in conduction-path length, response latencies decreased to adult values by 25-30 days of age, presumably reflecting the increased conduction velocity in the input fibers. In each age group three functional classes of neurons responsive to tactile stimulation of the footpads were identifiable. One consisted of slowly adapting neurons whose stimulus-response relations resembled those of the adult in responsiveness and dynamic range by 25-30 days postnatal age. The remaining neurons were purely dynamically sensitive, but among them two classes could be distinguished by their differential sensitivity to cutaneous vibration, one receiving rapidly adapting (RA) fiber input the other pacinian corpuscle (PC) input. The combined bandwidth of vibration sensitivity in dynamically sensitive cuneate neurons expands from approximately 5-300 Hz in the neonate to the mature range of 5-1,000 Hz by 1 mo of age. The PC class of cuneate neurons showed an upward shift in peak sensitivity from 30-200 Hz in the neonate to 100-300 Hz at 10-15 days, reaching adult values of 200-600 Hz by 25-30 days. Over this period absolute thresholds dropped by an order of magnitude at 200-500 Hz reflecting the threshold trends in primary PC fibers. During the first 1-2 postnatal months, the capacity of cuneate PC neurons to signal information in a pattern code about vibration frequencies around 300 Hz is restricted because of poor phase locking and low responsiveness, which preclude an impulse periodicity reflecting the vibratory frequency.(ABSTRACT TRUNCATED AT 400 WORDS)