The efficacy of psychotherapy, pharmacotherapy and their combination on functioning and quality of life in depression: a meta-analysis

BACKGROUND

There is growing recognition of the importance of both functioning and quality of life (QoL) outcomes in the treatment of depressive disorders, but the meta-analytic evidence is scarce. The objective of this meta-analysis of randomized controlled trials (RCTs) was to determine the absolute and relative effects of psychotherapy, pharmacotherapy and their combination on functioning and QoL in patients with depression.

METHOD

One hundred and fifty-three outcome trials involving 29 879 participants with depressive disorders were identified through database searches in Pubmed, PsycINFO and the Cochrane Central Register of Controlled Trials.

RESULTS

Compared to control conditions, psychotherapy and pharmacotherapy yielded small to moderate effect sizes for functioning and QoL, ranging from g = 0.31 to g = 0.43. When compared directly, initial analysis yielded no evidence that one of them was superior. After adjusting for publication bias, psychotherapy was more efficacious than pharmacotherapy (g = 0.21) for QoL. The combination of psychotherapy and medication performed significantly better for both outcomes compared to each treatment alone yielding small effect sizes (g = 0.32 to g = 0.39). Both interventions improved depression symptom severity more than functioning and QoL.

CONCLUSION

Despite the small number of comparative trials for some of the analyses, this study reveals that combined treatment is superior, but psychotherapy and pharmacotherapy alone are also efficacious for improving functioning and QoL. The overall relatively modest effects suggest that future tailoring of therapies could be warranted to better meet the needs of individuals with functioning and QoL problems.

Integrating molecular, phenotypic and environmental data to elucidate patterns of crocodile hybridization in Belize

The genus Crocodylus comprises 12 currently recognized species, many of which can be difficult to differentiate phenotypically. Interspecific hybridization among crocodiles is known to occur in captivity and has been documented between some species in the wild. The identification of hybrid individuals is of importance for management and monitoring of crocodilians, many of which are Convention on International Trade in Endangered Species (CITES) listed. In this study, both mitochondrial and nuclear DNA markers were evaluated for their use in confirming a suspected hybrid zone between American crocodile (Crocodylus acutus) and Morelet's crocodile (Crocodylus moreletii) populations in southern Belize where individuals and nests exhibiting atypical phenotypic features had previously been observed. Patterns observed in both phenotypic and molecular data indicate possible behavioural and ecological characteristics associated with hybridization events. The results of the combined analyses found that the majority of suspected hybrid samples represent crosses between female C. acutus and male C. moreletii. Phenotypic data could statistically identify hybrids, although morphological overlap between hybrids and C. moreletii reduced reliability of identification based solely on field characters. Ecologically, C. acutus was exclusively found in saline waters, whereas hybrids and C. moreletii were largely absent in these conditions. A hypothesized correlation between unidirectional hybridization and destruction of C. acutus breeding habitats warrants additional research.

The pattern of plasma sodium abnormalities in an acute elderly care ward: A cross-sectional study

INTRODUCTION

The combination of ageing, illness, and medications can lead to hyponatraemia or hypernatraemia.

AIMS

To describe the distribution of plasma sodium levels in older patients admitted to hospital.

METHODS

We carried out a hospital based cross-sectional study examining 1,511 serum sodium concentrations ([Na+]) among 336 elderly patients and attempted to elucidate the cause(s) of the abnormal serum [Na+].

RESULTS

The study population had a mean age of 81.4. Ninety-two (27.4%) patients had hyponatraemia and seven patients (2.1%) had hypernatraemia during their hospitalisation. The distribution of [Na+] results was towards the lower end of the normal range. The mortality rate of patients with hyponatraemia was 14.1% and that of patients with normal serum [Na+] was 8.9%. Six patients with hypernatraemia died in hospital. Lower respiratory tract infection and medication accounted for the majority of cases.

CONCLUSIONS

Deranged [Na+] is common among elderly patients admitted to hospital.

Presenilin-dependent regulated intramembrane proteolysis and gamma-secretase activity

Inhibiting the production of amyloid-beta by antagonising gamma-secretase activity is currently being pursued as a therapeutic strategy for Alzheimer's disease (AD). However, early pre-clinical studies have demonstrated that disruption of presenilin-dependent gamma-secretase alters many presenilin-dependent processes, leading to early lethality in several AD model organisms. Subsequently, transgenic animal studies have highlighted several gross developmental side effects arising from presenilin deficiency. Partial knockdown or tissue-specific knockout of presenilins has identified the skin, vascular and immune systems as very sensitive to loss of presenilin functions. A more appreciative understanding of presenilin biology is therefore demanded if gamma-secretase is to be pursued as a therapeutic target. Herein we review the current understanding of gamma-secretase complexes; their regulation, abundance of interacting partners and diversity of substrates. We also discuss regulation of the gamma-secretase complexes, with an emphasis on the functional role of presenilins in cell biology.

Genetic Variation in the Interleukin-10 Gene Promoter and Risk of Coronary and Cerebrovascular Events: The PROSPER Study

Proinflammatory cytokines, like interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha), are implicated in the development of atherosclerosis. The role of anti-inflammatory cytokines, like IL-10, is largely unknown. We investigated the association of four single nucleotide polymorphisms (SNPs) in the promoter region of the IL-10 gene (4259AG, -1082GA, -592CA, and -2849GA), with coronary and cerebrovascular disease in participants of the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) trial. All associations were assessed with Cox proportional hazards models adjusted for sex, age, pravastatin use, and country. Haplotype analysis of the four SNPs showed a significant association between haplotype 4 (containing the -592A variant allele) and risk of coronary events (P = 0.019). Moreover, analysis of separate SNPs found a significant association between -2849AA carriers with incident stroke (HR (95%CI) 1.50 (1.04-2.17), P value = 0.02). Our study suggests that not only proinflammatory processes contribute to atherosclerosis, but that also anti-inflammatory cytokines may play an important role.

The financial implications of falls in older people for an acute hospital

BACKGROUND

Falls are a common occurrence in older people and frequently lead to hospital admission. There is a current lack of cohesive fall prevention strategies in the Republic of Ireland.

AIM

To demonstrate the cost of fall-related admissions to an acute hospital.

METHODS

A review of Hospital Inpatient Enquiry (HIPE) data and medical case notes was performed for all fall-related admissions over a one-year period. The cost of fall-related admissions was calculated. In addition a detailed cost analysis was performed to determine the true cost of a hip fracture admission.

RESULTS

There were 810 fall-related admissions, resulting in 8,300 acute bed days, and 6,220 rehabilitation bed days, costing euros 10.3 million. Fall-related readmissions resulted in 650 bed-days, bringing the total cost to euros 10.8 million. A typical hip fracture incident admission episode costs euros 14,300.

CONCLUSION

Fall-related admissions of olderpeople are a significant financial burden to the health service.

Antibiotic prescribing policy and Clostridium difficile diarrhoea

BACKGROUND

Broad-spectrum antibiotics, particularly intravenous cephalosporins, are associated with Clostridium difficile diarrhoea. Diarrhoea due to C. difficile is a growing problem in hospitals, especially among elderly patients.

AIM

To establish whether changing an antibiotic policy with the aim of reducing the use of injectable cephalosporins leads to a reduction in the incidence of C. difficile diarrhoea in elderly patients.

DESIGN

Retrospective analysis.

METHODS

A group of patients who were subject to the new antibiotic policy from the period following July 2000, were compared with patients who were admitted prior to July 2000 and were not subject to the new policy. Infections, antibiotic prescriptions and mortality rates were determined from case notes, and C. difficle diarrhoea rates from microbiological data.

RESULTS

Intravenous cephalosporin use fell from 210 to 28 defined daily doses (p < 0.001) following the change in antibiotic policy, with a corresponding increase in piperacillin-tazobactam (p < 0.001) and moxifloxacin (p < 0.001) use. The new policy led to a significant reduction in C. difficile diarrhoea cases. The relative risk of developing C. difficile infection with the old policy compared to the new policy was 3.24 (95%CI 1.07-9.84, p = 0.03).

DISCUSSION

The antibiotic policy was successfully introduced into an elderly care service. It reduced both intravenous cephalosporin use and C. difficile diarrhoea.

Cell–cell contact and membrane spreading in an ultrasound trap

An ultrasonic standing wave trap [Langmuir 19 (2003) 3635] in which the morphologies of 2-D latex-microparticle aggregates, forming a pressure node plane, were characterised has been applied here to different cell suspensions with increasing order of specificity of cross-linking molecule, i.e. polylysine with chondrocytes; wheat germ agglutinin (WGA) with erythrocytes and surface receptors on neural cells. The outcome of initial cell-cell contact, i.e. whether the cells stuck at the point of contact (collision efficiency = 1) or rolled around each other (collision efficiency = 0), was monitored in situ by video-microscopy. The perimeter fractal dimensions (FD) of 2-D hexagonally symmetric, closely packed aggregates of control erythrocytes and chondrocytes were 1.16 and 1.18, respectively while those for the dendrititc aggregates formed initially by erythrocytes in 0.5microg/ml WGA and chondrocytes in 20 microg/ml polylysine were 1.49 and 1.66. The FDs for control and molecularly cross-linked cells were typical of reaction-limited aggregation (RLA) and transport diffusion-limited aggregation (DLA), respectively. The FDs of the aggregates of cross-linked cells decreased with time to give more closely packed aggregates without clear hexagonal symmetry. Suspensions of neural cells formed dendritic aggregates. Spreading of inter-cellular membrane contact area occurred over 15 min for both erythrocyte and neural cell dendritic aggregates. The potential of the technique to characterise and control the progression of cell adhesion in suspension away from solid substrata is discussed.

Relationship between metabolism and peripheral blood mononuclear cell mitochondrial complex I activity before and after a short-term refeeding in weight-losing cancer patients

BACKGROUND AND AIMS

Previous investigations showed that mitochondrial complex I activity seems to be a specific marker of dietary malnutrition in human. Since cancer has a more complex etiology than simple calorie deficiency, the aim of this study was to investigate the relationship between mitochondrial complex I activity and cancer.

METHODS

Nine cancer patients (CaPs) with weight loss and 14 age-matched healthy volunteers (HVs) were recruited. Body mass index (BMI), body composition as well as resting energy expenditure (REE) and RQ were measured. Mitochondrial complex I activity was measured as described previously in isolated peripheral blood mononuclear cells. Six patients were investigated again after 7 days of refeeding.

RESULTS

Weight loss in CaPs was mainly due to a loss of fat mass (FM), while fat-free mass (FFM) was preserved. The RQ was significantly lower in CaPs compared to HVs (P<0.001) and peripheral blood mononuclear cell complex I activity was significantly correlated with the %FM and RQ in CaPs. Furthermore, complex I activity increased significantly after 1 week of refeeding.

CONCLUSIONS

Our study showed that mitochondrial complex I activity was inversely correlated to parameters of increased fat oxidation and reduced FM, which are indices of dietary insufficiency rather than loss of lean body mass, which is an index of increased catabolism in cancer.

Anticonvulsant use in elderly patients in long-term care units

BACKGROUND

Elderly patients in long-term care units are frailer than their community-dwelling peers and may be more at risk from toxic side-effects of anticonvulsant medication at standard doses.

AIM

To examine the prescribing of anticonvulsants to patients in elderly care units.

METHODS

Drug prescription sheets and case notes were reviewed. Serum anticonvulsant concentration, renal and liver profiles and albumin level were measured.

RESULTS

Anticonvulsants were prescribed to twice as many male as female patients (32 vs 14%; p<0.03) and to 33% of those younger than 80 years of age versus 10% of those aged 80 years or older (p<0.0002). No patient had significant hypoalbuminaemia and routine measurement of serum anticonvulsant concentration did not indicate an alteration of dosage.

CONCLUSIONS

Anticonvulsants appear to be well tolerated in these patients. The younger age of those receiving anticonvulsants is inadequately explained by the characteristics of the patient cohort and may reflect a shift towards a younger age in patients requiring anticonvulsants due to increased mortality in this group.

Testing cognitive function in elderly populations: the PROSPER study. PROspective Study of Pravastatin in the Elderly at Risk

OBJECTIVES

For large scale follow up studies with non-demented patients in which cognition is an endpoint, there is a need for short, inexpensive, sensitive, and reliable neuropsychological tests that are suitable for repeated measurements. The commonly used Mini-Mental-State-Examination fulfils only the first two requirements.

METHODS

In the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER), 5804 elderly subjects aged 70 to 82 years were examined using a learning test (memory), a coding test (general speed), and a short version of the Stroop test (attention). Data presented here were collected at dual baseline, before randomisation for active treatment.

RESULTS

The tests proved to be reliable (with test/retest reliabilities ranging from acceptable (r=0.63) to high (r=0.88) and sensitive to detect small differences in subjects from different age categories. All tests showed significant practice effects: performance increased from the first measurement to the first follow up after two weeks.

CONCLUSION

Normative data are provided that can be used for one time neuropsychological testing as well as for assessing individual and group change. Methods for analysing cognitive change are proposed.

New onset seizures in the elderly: aetiology and prognosis

Late onset epilepsy is increasing in incidence. These patients often have significant underlying morbidity. This retrospective study in a tertiary referral centre identified 68 patients aged 65 years or older, with new onset seizures over a four-year period. 81% of patients (n = 55) were followed up at an average of 2.7 years post diagnosis. 38% of patients had evidence of cerebrovascular disease (CT visualised focal infarction, haemorrhage or small vessel ischaemia in 32%, clinical diagnosis with normal CT brain in 6%). No patient was found to have a space-occupying lesion. Of the 55 patients followed up, 45% of these had died at a mean age of 82 years old and 1.9 years post diagnosis (range 12 hours to 5 years). Three patients died as a direct result of seizures (trauma and sepsis). 14 patients died of clearly unrelated causes. Eight patients died from underlying vascular disease or Alzheimer's dementia. Patients who died during follow-up were on average 3.4 years older at the time of diagnosis than survivors (p< 0.05). Patients with atrial fibrillation at the time of diagnosis, had increased mortality (relative risk 2.53; 95% C.I. 1.19 - 5.36), but they were older than those without atrial fibrillation. At the time of follow up, 92% of those taking anti-convulsants were maintained seizure free on anticonvulsant monotherapy.

Telephone contacts with a cancer nurse specialist

AIM

The objective of this study was to audit the nature of telephone consultations with a Macmillan nurse specialist.

METHOD

All calls made to or by a Macmillan nurse over a period of 20 days were analysed in respect of three main areas: symptom management, psychological support and treatment. Information was recorded on a data sheet and then data were collected and descriptive statistics were produced.

RESULTS

The mean length of call was eight minutes. Most calls were incoming and involved patients, followed by relatives and healthcare professionals. The majority of calls involved psychological support, followed by symptom management then treatment.

CONCLUSION

The data show that the Macmillan nurse specialist spends a large amount of time in telephone work, mainly in consultation with patients.

Antibiotic resistance--an alarming health care issue

Emerging highly infectious viral agents, resurgent diseases, and mutating bacteria have created a significant and costly health care crisis. Antibiotics that were proven to be definitive weapons against infectious disease now are losing their effectiveness. This article describes the etiology and impact of this global problem and offers perioperative nurses and other health care professionals guidelines about basic infection control and infectious disease prevention to help combat this crisis.

The NIMA-related kinase X-Nek2B is required for efficient assembly of the zygotic centrosome in Xenopus laevis

Nek2 is a mammalian cell cycle-regulated serine/threonine kinase that belongs to the family of proteins related to NIMA of Aspergillus nidulans. Functional studies in diverse species have implicated NIMA-related kinases in G(2)/M progression, chromatin condensation and centrosome regulation. To directly address the requirements for vertebrate Nek2 kinases in these cell cycle processes, we have turned to the biochemically-tractable system provided by Xenopus laevis egg extracts. Following isolation of a Xenopus homologue of Nek2, called X-Nek2B, we found that X-Nek2B abundance and activity remained constant through the first mitotic cycle implying a fundamental difference in Nek2 regulation between embryonic and somatic cell cycles. Removal of X-Nek2B from extracts did not disturb either entry into mitosis or the accompanying condensation of chromosomes providing no support for a requirement for Nek2 in these processes at least in embryonic cells. In contrast, X-Nek2B localized to centrosomes of adult Xenopus cells and was rapidly recruited to the basal body of Xenopus sperm following incubation in egg extracts. Recruitment led to phosphorylation of the X-Nek2B kinase. Most importantly, depletion of X-Nek2B from extracts significantly delayed both the assembly of microtubule asters and the recruitment of gamma-tubulin to the basal body. Hence, these studies demonstrate that X-Nek2B is required for efficient assembly of a functional zygotic centrosome and highlight the possibility of multiple roles for vertebrate Nek2 kinases in the centrosome cycle.

The design of a prospective study of Pravastatin in the Elderly at Risk (PROSPER). PROSPER Study Group. PROspective Study of Pravastatin in the Elderly at Risk

The PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) is a randomized, double-blind, placebo-controlled trial designed to test the hypothesis that treatment with pravastatin will diminish risk of subsequent major vascular events in a cohort of men and women (70 to 82 years old) with preexisting vascular disease or significant risk of developing this condition. Five thousand eight hundred four men and women in addition to receiving advice on diet and smoking, have been randomized equally to treatment with 40 mg pravastatin/day or matching placebo in 3 centers (Cork, Ireland, Glasgow, Scotland, and Leiden, The Netherlands). Following an average 3.5-year intervention period, a primary assessment will be made of the influence of this therapy on major vascular events (a combination of coronary heart disease, death, nonfatal myocardial infarction, and fatal and nonfatal stroke). A number of additional analyses will also be conducted on the individual components of the primary end point, on men, on women, and on subjects with and without previous evidence of vascular disease. Finally, an assessment will be made of the effects of treatment on cognitive function, disability, hospitalization or institutionalization, vascular mortality, and all-cause mortality.

Cardiac ventricular support. Considerations for psychiatry

Cardiac ventricular support is fostering additional roles for psychiatric consultation with this vulnerable end-of-life cardiac group. Incidence of premorbid and postsurgical psychiatric disorders (Axis I), psychotropic use, neurologic events, and mortality was obtained for 21 Novacor left-ventricular assist system patients prospectively and 13 Abiomed left/right ventricular-assist device patients retrospectively. This fragile patient population and their families warrant involvement for psychiatry because of the extreme conditions and consequences associated with mechanical cardiac assistance. The authors address psychiatric morbidity and neurobehavioral modifications associated with ventricular support.

Heart transplantation in patients with heparin-induced thrombocytopenia on the Novacor left ventricular assist system

We report on two patients with development of heparin-induced thrombocytopenia with thrombosis while on the Novacor left ventricular assist system. Heart transplantation was successfully performed in both patients with heparin used for cardiopulmonary bypass after careful monitoring of heparin-associated antibodies. The approach to the patients' management and potential alternatives for anticoagulation are discussed.

The significance of basal systolic murmurs in the elderly

Aortic stenosis is common in the elderly. Basal systolic murmurs are also common. We studied 512 patients over the age of 65 years to ascertain the prevalence of basal systolic murmurs and by using echocardiography on those with basal murmurs to determine the prevalence of significant aortic stenosis. 29% (148) of patients had basal systolic murmurs. 81 (55%) patients of this group had echocardiography carried out and 21 (25.9%) had a gradient across the aortic valve of 30 mmHg or more.

The effects of hospital admission on drug prescribing in an elderly population

307 consecutive patients admitted to our unit were studied. The reasons for altering patients' drug regimens were noted. The price difference between the patients' drugs on admission to those on discharge was calculated. While over 40% of drugs regimens on admission were unchanged on discharge some adjustments were made in the remainder. The most common reason for stopping a drug was that the hospital physician could find no indication for its use. A 30.3% reduction in price of discharge drugs compared with drugs on admission was achieved.

Rectal examination in hospital patients

Rectal examination should be part of the initial examination of the patient especially those who are over the age of 50 and/or those with gastro intestinal and genito-urinary symptoms. We assessed the rate of rectal examinations carried out on acute general medical and surgical admissions over the age of 50 years.

Patient throughput in an acute geriatric unit

This report presents findings from a 3-year investigation of patient turnover, morbidity and mortality in the department of geriatric medicine based at Cork University and St. Finbarr's Hospitals, Cork. A total of 3,977 patients were admitted during the study period. The majority were 70 years or over (89%), referred by a general practitioner (83%) and female (56%). Seventy-one percent of admissions were discharged home, a further 18% died within the unit while 11% were transferred to continuing care. The median duration of stay was ten days. Age, diagnosis and source of referral significantly influenced both patient outcome and duration of stay. Forty-seven percent of discharged patients were followed-up at either the day hospital or outpatient clinic. A morbidity profile was constructed for a representative sample of 318 patients. 52% of this sample had two or more significant diagnoses. Neurological disorders carried a particularly poor prognosis. The median duration of stay for patients transferred to an on-site long stay facility was approximately one year.

The incidence of gastroesophageal reflux with the laryngeal mask: a comparison with the face mask using esophageal lumen pH electrodes

To test the hypothesis that the laryngeal mask airway (LMA) predisposes patients to gastroesophageal reflux, we randomly assigned 55 patients having elective surgery to receive standardized anesthesia with the LMA or with conventional face mask (FM) plus airway. A pH-sensitive probe with two electrodes, 10 cm apart, was passed nasally into the esophagus 1 h before induction of anesthesia, and recordings were made continuously until 30 min after surgery. At the distal electrode, 30 cm from the anterior nares, there was a significant difference in the incidence of reflux: 53.6% with the LMA versus 22.2% with the FM (P < 0.05). At the level of the proximal electrode, 20 cm from the anterior nares, there was no difference between groups. Multiple reflux events, defined as two or more reflux events before, during, or after anesthesia, were significantly more frequent in the LMA group (P < 0.05). Reflux events continued in the postanesthesia care unit (PACU) in both groups with no significant difference between groups. There was no clinical evidence of aspiration of gastric contents in either group. Use of the LMA appears to result in increased reflux to the level of the mid to upper esophagus, and is associated with a more frequent incidence of multiple reflux events than use of the FM.

Fatal vertebral giant cell arteritis

Death due to giant cell arteritis (GCA) is rare, and is usually caused by coronary or vertebral arteritis in the acute phase of the disease. A case of fatal GCA is reported in a woman with a normal erythrocyte sedimentation rate, who had been treated for temporal arteritis for eight months. Post mortem examination showed a dissection and thrombosis of the intracranial portion of the left vertebral artery caused by giant cell arteritis. Focal coronary artery GCA was also found. As far as is known, this is the only case in which dissection of the vertebral artery attributable to GCA has been reported.

Do elderly patients mind how doctors address them?

A survey was carried out in the Geriatric Unit at Cork Regional Hospital to determine how elderly patients would like to be addressed by their doctor. Two hundred patients over the age of 65 were given a Questionnaire asking them to state their preference. Only a minority (4.5%) expressed a definite preference for the formal mode of address. The remainder either did not mind (38%) or preferred to be addressed by their first name (57.5%). We concluded that most elderly patients do have a preference and this should be established on admission.

Regular planned respite admissions to a geriatric unit

A programme of regular planned respite admissions to the geriatric unit in Cork was established in 1984, for dependent elderly being cared for at home. Retrospective analysis of the respite programme sought to establish its bed utilisation, type of patients admitted, factors in their selection process, their outcome and any associated hospital morbidity. Twenty-four patients have used the scheme during the four years since its commencement, with an efficiency of bed utilisation in 1987 of 14 patients occupying a mean of 4.33 beds per month. The median number of medical problems per patients was five; their median age 77 years and the percentage over 80 years was 46%. Twenty-two patients were already receiving intensive rehabilitation before being placed on the programme, mobility problems dominated. Nine patients continue on the programme with a mean of 23.9 months of respites to date, eight were discharged and seven died. There was no significant difference between the number of respite stays in hospital and "at home" stays complicated by morbidity. The results suggest that even for a highly selected group of dependent elderly, a planned programme of respite admissions is an effective form of care, uses hospital beds efficiently without associated morbidity and may provide an alternative to long stay institutional care.

GR 38032F (ondansetron), a selective 5HT3 receptor antagonist, slows colonic transit in healthy man

The newly recognized class of 5-hydroxytryptamine receptors (5HT3) may be involved in the induction of nausea, since their pharmacological antagonists are effective against emesis induced by chemotherapy. 5HT3 receptors are present on enteric neurons, and 5HT3 blockers may produce mild constipation; we thus hypothesized that 5HT3 receptors would modulate colonic motility. To determine if GR 38032F, a selective 5HT3 antagonist known to have antiemetic effects, influences colonic transit in health, a randomized, double-blind, placebo-controlled crossover study was performed. Using a radiopaque marker technique, colonic transit was quantified in 39 healthy volunteers (19 men, 20 nonpregnant women) 18-70 years of age. On a standard 25-g fiber diet, 16 mg of GR 38032F was given orally thrice daily. Gastrointestinal peptides (peptide YY, human pancreatic polypeptide, neurotensin, motilin, gastrin-cholecystokinin, substance P) were also measured in plasma fasting and postprandially. Mean total colonic transit time on placebo was 27.8 hr, while on GR 38032F it was 39.1 hr (P less than 0.0005). Transit times through the left colon (P less than 0.0005) and rectosigmoid (P less than 0.05) were prolonged by the drug, but right colonic transit was not significantly altered. Transit times did not correlate with age or gender, but subjects with shorter transit times were significantly more affected than were those with longer transit times. The peak release of peptide YY was minimally decreased following GR 38032F (P less than 0.01), but the peak and integrated postprandial responses of human pancreatic polypeptide, neurotensin, motilin, gastrin-cholecystokinin, and substance P were not significantly altered by the drug.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of selective 5HT3 antagonist (GR 38032F) on small intestinal transit and release of gastrointestinal peptides

Antagonists of 5-hydroxytryptamine type 3 (5HT3) receptors reduce the nausea induced by cisplatinum, but the effects of these agents on 5HT3 receptors in the human gut remain to be defined. We examined the actions of one of these drugs (Glaxo GR 38032F) on small intestinal transit and mouth-to-cecum transit times in healthy man. We also quantified its effects on the release of peptide YY (PYY), neurotensin, human pancreatic polypeptide, gastrin-cholecystokinin, and motilin. Ten healthy volunteers were enrolled in a randomized, double-blind, placebo-controlled crossover study. Following a single intravenous dose of GR 38032F (0.15 mg/kg), we measured the time to appearance in plasma of sulfapyridine after injection of salicylazosulfapyridine into the duodenum. This was used as a measure of duodenocecal transit. The appearance of hydrogen in breath after ingestion of a meal containing lactulose was also correspondingly used to quantify the mouth-to-cecum transit of the "head" of the meal. Gastrointestinal hormones were assayed in plasma by specific RIAs; samples were drawn fasting (10 min after injection) and after breakfast (358 calories: 15.7 g protein, 55.4 g carbohydrate, 8.1 g fat). The postprandial integrated response and peak release of PYY was decreased by GR 38032F. There was also a trend for the peak release of neurotensin to be reduced. GR 38032F did not significantly alter small intestinal transit times or mouth-to-cecum transit times. We conclude that GR 38032F does not have a major effect on small intestinal transit in health.

The role of computed tomography brain scan in the diagnosis of acute stroke in the elderly

In order to document the frequency with which nonvascular pathology may mimic stroke syndromes in the elderly, we prospectively studied 100 such admissions to a geriatric unit. Of 81 patients evaluated with computed tomography (CT) brain scan or autopsy only one patient with tumour (1.2%) was identified and this case is discussed fully. Nineteen patients did not have a CT scan or autopsy, though their presentation and clinical course was consistent with vascular pathology. This paper stresses the importance of documenting a comprehensive history and of regular clinical assessment of patients to identify atypical features which would alert the physician to consider nonvascular pathology. The incidence of nonvascular pathology presenting as stroke in the elderly is low. We conclude that CT brain scan is not indicated in the diagnosis of stroke in patients presenting to a geriatric unit.