Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

The safety and efficacy of indinavir and ritonavir (400/400 mg BID) in HIV-1-infected individuals from an inner-city minority population: a pilot study

We evaluated the safety and efficacy of indinavir 400 mg and ritonavir 400 mg twice daily (RIT/IND 400/400) in HIV-1-infected individuals, using an open label, proof of concept study. All patients received indinavir 400 mg and ritonavir 400 mg twice daily. Patients were followed up to 48 weeks. Nineteen subjects were enrolled, 11 (58%) men and eight (42%) women. The majority were American Black (nine; 47%) or Haitian (eight; 42%). The median baseline plasma HIV-1 viral load (VL) was 5.13 log10 copies/mL and the median CD4 cell count was 112 cells/mm3. The proportion of compliant patients with VL <400 copies/mL at week 24 was 60% compared with 0% for non-compliant patients ( P=0.011 [intent-to-treat] or P=0.085 [on-treatment]). VL at week 4 predicted week 24 VL response. Compliant patients had a median average CD4 cell count increase of 83.2 cells/mm3 compared with 42.0 cells/mm3 for non-compliant patients (P=0.010). The median average changes in triglycerides and cholesterol were significantly higher in compliant patients.

This is a potent, safe combination for the treatment of HIV-1. VL at week 4 is predictive of viral outcome at week 24. Fasting serum cholesterol and triglycerides were significantly elevated during the study.

Validity of a questionnaire in estimating restorative treatment need among young adults

OBJECTIVE

There are no verified anamnestic sets of questions for assessing restorative treatment need. Finnish conscripts responded to a computer-based questionnaire on oral health during their oral health screening in 2011. This study compared the outcomes of the screening and the questionnaire concerning restorative treatment need with the aim of finding and validating a set of questions with the best association between the two methods.

CLINICAL SETTING

The study group comprised 8,566 conscripts. Of 50 original questions, 22 questions were chosen for closer analysis. The generalised linear mixed model was used to calculate the OR values (95% CI) for each of these questions, using restorative treatment need at individual level as the response variable. Questions with the best association (Q1-Q10) were selected for the final set; the inclusion criterion was p < 0.05. The area under curve (AUC) value was calculated for the sum function of these 10 questions.

RESULTS

Among the final set of 10 questions, the OR values varied between 1.12 and 4.61. The AUC value was 0.75. By increasing the number of positive responses to 8 questions, the odds for restorative treatment need were OR 69.27 and increased to infinity with 10 questions.

CONCLUSIONS

A selected set of questions together with clinical screening, or even alone, can be a valid instrument for screening people for restorative treatment need. The method is particularly useful in large populations. This statistical method might identify appropriate sets of questions for different contexts.

Geographical distribution of dental caries prevalence and associated factors in young adults in Finland

Oral health of the young has been reported to be associated with the place of residence, due to differences in socio-economic status. The results of studies on the effect of fluoride in drinking water on caries prevalence have been contradictory. The main aim of our study was to investigate the geographical distribution of dental caries prevalence in Finland and analyse possible regional, associated factors. Oral health of 13,564 men born between 1990 and 1992 was screened using a method based on criteria of the World Health Organization for epidemiological studies by 15 calibrated dentists in 20/24 garrisons of the Finnish Defence Forces in 2011. Mean DMFT and DT values in provinces were calculated. Multilevel analysis was applied to the data using generalized linear mixed models and a logit link function. The binary outcome variable was the cariological treatment need (yes/no) and the garrison was treated as random effect. Mean DMFT and DT values varied significantly between provinces in Finland. Increased levels of fluoride in drinking water, Swedish as the main language in the municipality, and living in urban areas were protective factors against cariological treatment need. Dentist density did not affect caries prevalence. The geographical distribution of dental caries further supported estimates of the protective effects of high fluoride levels in drinking water, Swedish as the main language in the municipality, as well as living in urban areas. Effect of fluoride on caries prevalence still exists, and association with the socio-economic status was confirmed.

The androgen receptor DNA-binding domain determines androgen selectivity of transcriptional response

The AR (androgen receptor) is a hormone-dependent transcription factor that translates circulating androgen hormone levels into a physiological cellular response by directly regulating the expression of its target genes. It is the key molecule in e.g. the development and maintenance of the male sexual characteristics, spermatocyte production and prostate gland development and growth. It is also a major factor in the onset and maintenance of prostate cancer and a first target for pharmaceutical action against the further proliferation of prostate cancer cells. The AR is a member of the steroid hormone receptors, a group of steroid-inducible transcription factors sharing an identical consensus DNA-binding motif. The problem of how specificity in gene activation is achieved among the different members of this nuclear receptor subfamily is still unclear. In this report, we describe our investigations on how the AR can specifically activate its target genes, while the other steroid hormone receptors do not, despite having the same consensus monomeric DNA-binding motif. In this respect, we describe how the AR interacts with a newly identified class of steroid-response elements to which only the AR and not, for example, the glucocorticoid receptor can bind.

Dose linearity of inhaled fentanyl (FT) with comparative pharmacokinetics to transmucosal fentanyl (A)

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Background: Cancer patients frequently experience breakthrough pain which is a transitory flare of moderate or severe pain occurring on top of otherwise controlled, persistent pain. Fentanyl TAIFUN (FT), a novel breath-actuated dry powder inhaler is being developed for the treatment of breakthrough cancer pain in patients with ongoing opiate therapy. Methods: A randomized, open-label, crossover phase I study with 5 periods derived pharmacokinetics after fentanyl oromucosal (Actiq, A) and pulmonary (FT) administration in 30 healthy volunteers. Each single dose of study medication (200 mcg A; or 100, 200, 400 or 800 mcg FT) was administered following premedication with 50 mg of naltrexone with a minimum of 7 days between doses. Pharmacokinetic parameters were calculated from the plasma concentrations using a non-compartmental model. Results: The plasma concentrations of FT increased proportionally to the increasing dose and t1/2 was independent of the dose. FT had a linear elimination phase. FT had a substantially faster absorption and higher peak fentanyl concentration (Cmax) than A. Median Tmax was 1 and 60 min for FT and A, respectively. Moreover, there was an 8-fold increase in bioavailability of fentanyl during the first 20 min when 200 mcg FT is compared to 200 mcg A. Conclusions: The plasma concentrations from FT increases proportionally to the increasing dose while t1/2 is independent of the dose, and there is a linear elimination phase. Overall, FT is substantially more bioavailable than A during the important first 20–30 minutes after administration. Inhalation of FT allows an immediate and comparable availability of fentanyl suggesting potential for rapid pain relief.

[Table: see text]

[Table: see text]

Effectiveness and tolerability of a once-daily amprenavir/ritonavir-containing highly active antiretroviral therapy regimen in antiretroviral-naïve patients at risk for nonadherence: 48-week results after 24 weeks of directly observed therapy

OBJECTIVES

To determine the safety and effectiveness of a once-daily highly active antiretroviral therapy (HAART) regimen in patients at risk for poor adherence using directly observed therapy (DOT) for 24 weeks followed by weekly phone contact for another 24 weeks.

METHODS

A prospective, open-label pilot study was carried out. Antiretroviral-naïve patients with advanced HIV disease were treated with once-daily amprenavir 1200 mg, ritonavir 200 mg, didanosine 400 mg and lamivudine 300 mg. After 24 weeks, DOT was substituted by weekly phone contact. Measurements of viral load and CD4 cell count, and safety laboratory measurements, were taken regularly for 48 weeks.

RESULTS

Twenty-two patients were enrolled in the study, of whom 19 completed at least 4 weeks of treatment. Seventeen patients completed 24 weeks and 13 completed 48 weeks. None discontinued treatment as a result of adverse events. The median baseline HIV viral load was 5.29 log(10) HIV-1 RNA copies/mL and the median CD4 cell count was 20 cells/microL. At weeks 24 and 48, 74% of the patients had viral loads <400 copies/mL. At 48 weeks, the median decrease in viral load from baseline was 3.06 log(10) copies/mL, and the median increase in CD4 cell count was 118 cells/microL. The median trough plasma amprenavir concentrations at weeks 1 and 24 were 1.87 and 1.42 microg/mL, respectively.

CONCLUSIONS

This study suggests that DOT followed by weekly patient contact results in good treatment outcome in this challenging population. The median trough plasma amprenavir concentrations were above the effective concentration of drug that resulted in 90% inhibition of viral load in vivo (EC(90)) for wild-type HIV.

Reoperative coronary bypass surgery using normothermic cardiopulmonary bypass: comparison with first-time procedures

Redo coronary artery bypass grafting (CABG) is characterized by increased patient risk compared with first-time CABG. The reason for higher risk is not completely understood but it is logically related to inadequate myocardial preservation evidenced by the higher incidence of postoperative low-output syndrome. We compared normothermic cardiopulmonary bypass with cold blood maintenance cardioplegia in both first-time and redo CABGs to determine whether this single approach is appropriate for both instances. Five hundred seventeen consecutive CABG patients were retrospectively reviewed. Four hundred fifty-four first-time CABG procedures were compared with 44 redo procedures. All aspects of the operation were identical including myocardial preservation. Retrospective univariant analysis of both groups followed. Three clinical features distinguished first-time versus redo CABG. These were previous percutaneous transluminal coronary angioplasty (first-time 19% vs redo 71%; P < 0.001), preoperative intra-aortic balloon pump (first-time 38% vs redo 71%; P < 0.001), and Parsonnet risk score (first-time 11.7+/-8.2 vs redo 19.2+/-8.8; P < 0.001). Operative mortality for redo CABG was higher than in first-time procedures (3.4% vs 6.4%; P = not significant), although small sample size limited statistical significance. The length of stay was statistically longer in redo patients (8.7+/-10.8 vs 6.0+/-5.1 days; P < 0.01) and is related to a higher Parsonnet score, increased postoperative pneumonia, and failed percutaneous transluminal coronary angioplasty before redo CABG. We conclude that redo CABG is a different operation from first-time procedures and requires enhanced myocardial preservation. Normothermic cardiopulmonary bypass with cold blood maintenance cardioplegia does not appear to achieve this goal.

Writing a coding success story: best practices and beyond. Panel discussion

What are the cornerstones of a thriving coding department? How can you ensure your coding team is built on a foundation of education, compliance, and satisfaction? We spoke with several coding managers to collect solutions and guidance for common coding challenges.

Conventional coronary artery bypass grafting: why women take longer to recover

BACKGROUND

Recovery following successful coronary artery bypass grafting (CABG) has been dramatically improved with the use of fast-track methods. Although data exist that demonstrate a significant gender difference in survival following CABG, little is known about factors influencing gender-specific recovery. This report describes a series of consecutive patients undergoing isolated CABG to determine gender-associated factors that may impact outcomes and recovery.

METHODS

Five hundred and seventeen consecutive patients underwent isolated CABG utilizing cardiopulmonary bypass and were retrospectively reviewed. The outcomes of 351 men in the study were compared to the group of 160 women. A rapid recovery protocol focused on reduced cardiopulmonary bypass time, aggressive preoperative intra-aortic balloon pump use, early extubation, perioperative administration of corticosteroids and thyroid hormone, aggressive diuresis and atrial fibrillation prevention was applied to all patients.

RESULTS

The 30-day mortality rate for the women was 4.2% (Parsonnet risk 16.3+/-9.0) compared with 3.4% (Parsonnet risk 9.9+/-7.5) for the men. There were no statistically significant differences in the 30-day mortality rates or postoperative complication rates between the women and men. The women, however, were found to be older (71+/- years versus 65+/- years, p<0.001), and to have a higher incidence of acute myocardial infarction (31% versus 20%, p<0.05), obesity (23% versus 10%, p <0.05), diabetes (31% versus 22%, p<0.05), hypertension (65% versus 48%, p<0.001), and symptomatic vascular disease (20% versus 12%, p<0.05). The women required fewer bypass grafts (2.9 versus 3.5 grafts, p<0.001), and consequently, had shorter cross and cardiopulmonary bypass times. Rapid recovery with discharge before the fifth postoperative day was achieved in 30% of the women, in comparison to 44% of the men (p<0.01). The postoperative hospital length of stay was longer for the women in comparison to the men (7.2+/-7.1 versus 5.8+/-5.2 days, p<0.05).

CONCLUSIONS

Women had similar operative mortality and postoperative complication rates to men under a rapid recovery protocol. However, women have a longer recovery interval compared to men, which may be a reflection of their higher preoperative risk profile.

Simplified Parsonnet risk scale identifies limits to early patient discharge

BACKGROUND

Fast-track recovery after coronary artery bypass surgery has influenced patient care positively. Predicting patients who fall off track and require prolonged (> or =7 days) hospitalization remains uncertain. The Parsonnet risk assessment score is effective in predicting length of stay, but is limited by inaccurate subdivision of risk categories. We simplified the Parsonnet risk scale to better identify patients eligible for fast-track recovery.

METHOD

The cases of 604 consecutive patients who underwent isolated coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB) were reviewed retrospectively. A rapid recovery protocol emphasizing reduced CPB time, preoperative intra-aortic balloon pump (IABP) criteria, and atrial fibrillation prophylaxis was applied to all patients. The five original divisions of the Parsonnet risk scale were reduced to three risk categories: Low (0-10; Group A), Intermediate (11-20; Group B), High (> 20; Group C). Comparisons of progressive risk categories were analyzed to identify predictive factors associated with fast-track outcomes.

RESULTS

The thirty-day operative mortality for the entire group was 3.6%. Three clinical features were identified that distinguished risk progression-female gender, reoperative CABG, and increased age. Additionally, the presence of diabetes (p < 0.05), congestive heart failure (p < 0.01), and peripheral vascular disease (p < 0.001) distinguished Groups A and B, while acute myocardial infarction (p < 0.05) influenced outcomes in Group C. Group A (48%) mean risk score 5.9+/-3.2 was compared to Group B (34%) 14.8+/-2.6, which was further compared to Group C (18%) 26.4+/-2.8. The mean length of stay for Group A (5.3+/-4.1 days) was notably less than Group B (6.1+/-4.7 days; p < 0.05); however, both groups responded favorably to fast-track techniques. Group C did not respond comparably (9.2+/-9.2 vs 6.1+/-4.7 days; p < 0.001) and experienced prolonged recovery. The simplified Parsonnet risk scale did not identify differences in operative mortality and revealed only pneumonia (p < 0.05) and atrial fibrillation (p < 0.01) to be greater in Group C. As risk increased, significantly less revascularization was performed (Group A 3.6+/-1.2 grafts/patient vs Group B 3.3+/-1.2 [p < 0.01]; Group B 3.3+/-1.2 vs Group C 2.5+/-1.0 [p < 0.001]).

CONCLUSION

A simplified Parsonnet risk scale (three categories) is an effective tool in identifying factors limiting fast-track recovery. Low- and intermediate-risk patients represent the majority (82%) and respond well to fast-track methods. High-risk patients (18%) are limited by a greater percentage of female patients, reoperative CABG, and the very elderly, resulting in fast-track failure. Strategies to improve recovery in high-risk patients may include evolving off-pump techniques.

Liquid medication dispensing and dose monitoring: the CycloTech Cyclosporine Oral Solution Dispenser

This liquid medication dispenser offers an easy, convenient means for accurate dispensing of medication. The ability of the device to store dose size, time to next dose, remaining available doses, and doses dispensed may allow for future analysis of patient behavior and improve compliance.

Rapid recovery of octogenarians following coronary artery bypass grafting

BACKGROUND

Rapid recovery protocols for coronary artery bypass grafting (CABG) have resulted in major decreases in postoperative hospital length of stay (LOS) when applied to younger patients undergoing elective procedures. However, the effectiveness of rapid recovery protocols when applied to octogenarians has not been thoroughly studied.

METHODS

Thirty-seven consecutive octogenarians underwent isolated CABG utilizing cardiopulmonary bypass (CPB). A protocol emphasizing preoperative placement of the intra-aortic balloon pump, reduced CPB time, early extubation, perioperative steroids, thyroid hormone, and aggressive postoperative diuresis was used.

RESULTS

The 30-day operative mortality for the entire series was 5.4%. Twenty-five patients (71%, group I) were discharged in < 10 days postoperatively (average LOS of 6.3 +/- 1.6 days), while ten patients (29%, group II) were discharged at 10 or more days postoperatively (average LOS of 20.3 +/- 8.0, p < 0.001). Patients in group II were found to have a higher incidence of obesity (50% vs 4%, p < 0.01), symptomatic peripheral vascular disease (60% vs 8%, p < 0.01), and preoperative ambulatory difficulties (50% vs 0%, p < 0.01). The incidence of complications was 31% for the entire series, with no differences between the groups.

CONCLUSION

Octogenarians performed well under a rapid recovery protocol, with 71% being discharged in < 10 days postoperatively, while patients with obesity, symptomatic peripheral vascular disease, and ambulatory difficulties rehabilitated more slowly.

Treatment planning for dental implants: considerations, indications, and contraindications

During the last 10 years the initial concept of osseointegrated implant dentistry as essentially treatment of the heavily resorbed edentulous mandible in older patients has expanded to encompass almost every combination of prosthetic problem. Many factors must be taken into account when planning treatment to ensure a flexible approach which is necessary given the uncertainty in predicting the outcome of difficult cases. The complex, and therefore inherently costly, nature of implant dentistry will inevitably lead the patient to have very high expectations of treatment. It is extremely important for the operator to determine these expectations at an early stage, and if there is any doubt about being able to satisfy them then he or she may be wiser not to proceed (as in all other areas of dentistry, skillful case selection is the key to success). In any event, the patient must be fully appraised of the complications, the potential risks and the benefits of treatment so that they can proceed on the basis of informed consent.

Inhibition of ex vivo neutrophil activation by oral LY293111, a novel leukotriene B4 receptor antagonist

1. The effects of orally administered LY293111 on ex vivo neutrophil Mac-1 upregulation were determined in a total of 24 healthy male subjects within three study periods. 2. In the first period, eight volunteers received 60 mg LY293111 or placebo three times daily in 22 total doses over 8 days followed by a 1 week follow-up. The average ex vivo Mac-1 response of the LY293111 group was 56% of the predose control (95% confidence interval (CI) 44.3 to 67.9%; P < 0.01). The inhibitory effect was maximum at the end of dosing and had disappeared by day 14. 3. In the second period, eight subjects received 120 mg LY293111 or placebo three times daily in 22 total doses over 8 days followed by a 1 week follow-up. The average response of the LY293111 group was 70% of the pre-dose control (95% CI 59.7 to 81.0%; P < 0.01). The inhibitory effect was maximum the day following the initial dose and continued throughout the dosing period. 4. In the third period, eight subjects received 200 mg LY293111 or placebo twice daily in 15 total doses over 8 days followed by a 1 week follow-up. Mac-1 upregulation was 64% of pre-dose levels (95% CI 53.8 to 75.1%; P < 0.01) over the course of the study period. The inhibition had disappeared 2 days following the final dose. Alternate neutrophil stimulation by fMLP was not inhibited. 5. No statistically significant inhibition was observed for placebo-treated subjects. 6. No statistically significant differences were apparent between the active dose regimens. 7. The results indicate that orally administered LY293111 is pharmacologically active in humans. Results from this study may be useful in determining dose selection for efficacy trials.

Absence of a sertraline-mediated effect on the pharmacokinetics and pharmacodynamics of carbamazepine

A double-blind, randomized, placebo-controlled study was conducted in 14 healthy male volunteers to assess the effects of sertraline on the pharmacokinetics and pharmacodynamics of carbamazepine.

METHOD

Subjects received carbamazepine 200 mg once daily for 2 days and every 12 hours thereafter. On Days 16 to 32, subjects also received either sertraline or placebo daily. The dose of sertraline was increased from 50 to 200 mg daily over 7 days; the 200-mg dose was given for 10 days. Samples for pharmacokinetic analyses were obtained on Days 15 and 32; trough plasma concentrations of carbamazepine and its principal metabolite, carbamazepine-10, 11-epoxide (CBZ-E), were determined daily beginning on Day 13. Cognitive function testing was performed on Day 1 before carbamazepine dosing (baseline), Day 15 (carbamazepine alone), and Day 32 (carbamazepine plus sertraline or placebo).

RESULTS

There were no significant differences between the sertraline and placebo groups in any of the pharmacokinetic parameters for carbamazepine or CBZ-E. Carbamazepine alone impaired cognitive function. The addition of sertraline did not potentiate these effects. Side effects were reported by 2 subjects in each group, but none were severe.

CONCLUSION

These findings indicate that sertraline does not affect the pharmacokinetics of carbamazepine or its principal metabolite and does not potentiate the cognitive effects of carbamazepine.

Circling behaviour in the rat following unilateral injections of p-chlorophenylalanine and ethanolamine-O-sulphate into the substantia nigra

Circling behaviour following the unilateral intranigral injection of the gamma-aminobutyric acid (GABA) transaminase inhibitor ethanolamine-O-sulphate, (EOS), or the tryptophan hydroxylase inhibitor p-chlorophenylalanine (pCPA) was compared, both for spontaneous circling and for circling induced by apomorphine administration. EOS-injected rats exhibited spontaneous contralateral rotation for up to 3 h after such injections. pCPA-injected rats showed only a slight ipsilateral postural asymmetry, both groups of rats elicited ipsilateral rotation upon apomorphine challenge. Increased ipsilateral dopamine release within the corpus striatrum accompanied this response. It is proposed that GABA and 5-HT may be closely related in modifying the nigrostriatal impulse flow.

Evidence for the existence of a raphe projection to the substantia nigra in rat

The effect of electrical stimulation of the median raphe nucleus on the activity of spontaneously firing single neurones in the substantia nigra and mesencephalic reticular formation (MRF) has been investigated in urethane anaesthetized rats. Depression of activity was the predominant effect observed although this was sometimes accompanied by periods of excitation. Some neurones were only excited. The latency of inhibition of substantia nigra neurones was constant whereas that of MRF neurones was more variable. Microiontophoretically applied 5-hydroxy-tryptamine (5-HT) and dopamine (DA) produced mainly inhibition of neuronal activity, but excitation and biphasic effects were also seen. There was a good correlation between the direction of neuronal responses in the substantia nigra to median raphe stimulation and to the effects of 5-HT but not DA. Discrete electrolytic lesions of the median raphe nucleus were followed by a decrease in 5-HT but not GABA concentrations in the substantia nigra. In addition striatal 5-HT, GABA and NA concentrations were unchanged whereas striatal DA was increased. These observations strongly suggest that the substantia nigra receives a direct inhibitory input from the median raphe nucleus and this pathway uses a 5-HT-like neurotransmitter. This pathway probably contributes to the regulation of nigrostriatal dopaminergic transmission.