Vagus nerve stimulation therapy for treatment-resistant epilepsy: a 15-year experience at a single institution

OBJECTIVE

Treatment-resistant epilepsy (TRE) occurs in 20-30% of patients. The goal of this study is to assess the efficacy and safety of vagus nerve stimulation (VNS) in this group of patients, including adult and pediatric populations and several off-label indications.

METHODS

This is a retrospective review of 59 consecutive patients in whom 60 VNS devices were implanted at a single institution during a 15-year period. Patients were evaluated in the Multidisciplinary Epilepsy Committee and complete presurgical workup was performed. The series included indications not approved by the FDA, such as children under 12 years of age, pregnancy and right-sided VNS. Performing the procedure on an out-patient basis was recently adopted, minimizing hospital length of stay.

RESULTS

There were 42 adults and 17 children (14 under 12 years of age) and the mean age at implantation was 26 years. Duration of VNS therapy ranged from 6 months to 9 years. For the entire cohort, the mean percentage seizure reduction was 31.37%. Twenty patients (34.48%) were considered responders (seizure reduction ≥50%); 7 patients (12.06%) had seizure reduction of ≥75% and 2 patients had seizure control of ≥90% (3.4%). The patient in whom right-sided VNS was implanted achieved the same reduction in seizure burden and the patient who became pregnant could reduce antiepileptic drugs dosage, without complications. Side-effects were mild and there were no permanent nerve injuries. One patient died in the follow-up due to psychiatric disorders previously known.

CONCLUSIONS

VNS is a safe and effective palliative treatment for TRE patients. There are an increasing number of indications and further randomized trials would potentially expand the number of patients who may benefit from it. A multidisciplinary team is crucial for a complete preoperative evaluation and selection of the optimal candidates for the treatment.

Biological responses to contaminants in the Humber Estuary: disentangling complex relationships

Due to the ecological importance of estuaries, it is necessary to understand the biological effects that potentially toxic contaminants induce in bioindicator species. A key aspect is whether effects at lower levels of biological organisation transfer through the system to higher levels. In understanding such processes, characterising multivariate relationships between contaminants, sediment toxicities and detoxification processes are important. Worms (Hediste diversicolor) and sediments were collected along the Humber Estuary, England, and inorganic and organic contaminants were quantified. Sediment toxicities and glutathione-S-transferases (GSTs) activity in the ragworm were analysed. Concentrations of metals were highest near urban and industrial areas, whereas organic contaminants appeared at upstream locations. GST activity correlated with heavy metals. The genotoxicity, oestrogenicity, dioxin and dioxin-like activity were higher at upstream locations. Oestrogenicity correlated with alkylphenols and some organochlorines, whilst genotoxicity correlated with organochlorines and heavy metals. Despite this, higher level biological responses could not be predicted, indicating that homeostasis is operating.

[Motor fluctuations and dyskinesias in Parkinson's disease: variables that discriminate both complications in a sample of 285 patients]

INTRODUCTION

A large proportion of patients with Parkinson's disease suffer fluctuations and dyskinesias in the course of the disease. The present study explores the variables that predict the appearance of these complications.

PATIENTS AND METHODS

This is a cross-sectional study that studies 285 patients with Parkinson's disease. Patient's age, date of diagnosis and of treatment with levodopa and motor situation (UPDRS III) were recorded. Drugs and doses were documented. Finally, levodopa equivalent dose in those patients using agonists or prolonged release formulations was calculated.

RESULTS

Mean age of the patients was 71.1 years (+/-9.1). Disease duration was 8.7 years (+/-11.8). A total of 118 patients (41.4%) presented motor fluctuations, and 61 patients (21.4 %) had dyskinesias. Two discriminant analytical models were established. In the first model, the dependent variable was the presence of fluctuations, and three variables significantly discriminated between the two groups: the levodopa equivalent dose, the duration of treatment with levodopa and the motor situation. In the second model the presence of dyskinesias constituted the dependent variable. The only variable selected by this model was the levodopa equivalent dose.

DISCUSSION

The duration of treatment with levodopa, the doses of agonists and levodopa and the motor situation differentiate patients with fluctuations from those without them. In the case of dyskinesias, only the agonists and levodopa doses were selected by the analytical model.

[Phenotypic characterisation of 35 Colombian children with an imaging diagnosis of schizencephaly]

INTRODUCTION

Schizencephaly is the most frequent neuronal migration disorder. It is classified according to the type of lip (closed or open). Clinical features vary from the asymptomatic patient to severe neurological compromise.

AIM

To describe the clinical characteristics of children who have been diagnosed with schizencephaly and their correlation with radiological findings.

PATIENTS AND METHODS

Thirty-five Colombian children (17 males and 18 females) with a neuroimaging diagnosis at a mean age of 20.2 months were characterised phenotypically.

RESULTS

A history of perinatal events such as neonatal asphyxia (21.6%) and meconium-stained amniotic fluid (10.8%) were detected, together with maternal histories of failure to attend prenatal check-ups (34.3%), risk of preterm labour (10.8%) and smoking (10.8%). Familial histories of neurological diseases included epilepsy (14.3%) and mental retardation (5.7%). The open-lip type was predominant (60%) and was twice a common as the closed-lip type. Unilateral cases accounted for 62.9% of the total number, with a distribution between the two hemispheres in the same proportion, and 37.1% of cases were bilateral. The frontal lobe that was the most commonly involved. The most frequent manifestations were delayed psychomotor development (80%) and infantile cerebral palsy (80%). Epilepsy was present in 37.1% of cases and the predominant type of seizure was complex focal.

CONCLUSIONS

Tendencies similar to those reported in other series were observed, although with some differences, such as the higher mean age at the time of diagnosis and the lower incidence of resistant epilepsy. Limited access to prenatal check-ups, open-lip presentation, associated malformations and poor response to treatment seem to exacerbate the prognosis.

[Safety and tolerability of olanzapine versus risperidone: a one-year randomized study in outpatients with schizophrenia with prominent negative symptoms]

OBJECTIVE

To evaluate the safety and tolerability of long-term treatment with olanzapine versus risperidone in schizophrenic outpatients with prominent negative symptoms.

METHODS

This was a multi-center, randomised, open-label, parallel, dose-flexible, 1 year study of outpatients with schizophrenia (DSM-IV criteria) with prominent negative symptoms (SANS Global score > or =10). Safety was evaluated by recording treatment-emergent adverse events, vital signs, body weight and, when available, laboratory parameters. Extrapyramidal symptoms (EPS) were evaluated by a questionnaire based on the UKU scale, and sexual dysfunction by the Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ).

RESULTS

The mean (+/- SD) modal dose throughout the study was 12.3 (+/- 6.3) mg/day for olanzapine and 5.2 (+/- 2.5) mg/day for risperidone. EPS were significantly more frequent in the risperidone-treated patients 50.4 % versus 28.9 % for olanzapine (p = 0.0006). Olanzapine patients showed significantly greater reductions (improvement) from baseline in the PRSexDQ score (p=0.0292) and risperidone patients reported significantly more sexual adverse events (21.1% versus 7.3% for olanzapine; p=0.0018). Mean body weight gain was not significantly different at endpoint (3.5 kg gained with olanzapine versus 1.9 kg gained with risperidone; p=0.3522), but the proportion of patients showing a body weight increase > or =7% was higher among the olanzapine-treated patients (37.8% versus 16.8%; p=0.0012).

CONCLUSIONS

Significantly less treatment-emergent extrapyramidal and sexual adverse events were observed in patients treated with olanzapine compared to those treated with risperidone. Mean body weight increases with both drugs were not significantly different after one year. Olanzapine patients presented a significantly higher incidence of clinically important body weight increase when compared with patients treated with risperidone.

[Utility of the study of the vegetative nervous system in the differential diagnosis between Parkinson's disease and multiple system atrophy]

INTRODUCTION

The aim of this study is to show if the exploration of the autonomic nervous system is useful to improve the specificity of clinical criteria of Parkinson's Disease (PD) and Multiple System Atrophy (MSA).

PATIENTS AND METHODS

20 patients with PD and 13 patients with MSA were studied. After 12 hours in off medication, NE and GH were measured in supine position and NE after 5 minutes standing. Later, GH levels were recorded at 15, 30, 45 and 60 minutes after a dose of 0.005 mg/kg of apomorphine. Finally, analysis of the symptoms of autonomic dysfunction and levodopa test were carried out.

RESULTS

Sympathetic response to postural changes was significantly higher in patients with PD (NE increase in relation to basal: PD: 170.90 +/- 110.08 pg/ml; MSA: 91.33 +/- 73.79 pg/ml; p = 0.029). No differences were found in the response of GH to apomorphine (GH peak at 45 minutes: PD: 2.37 +/- 2.7 ng/ml; MSA: 1.69 +/- 1.90 ng/ml; ns). The symptoms of autonomic dysfunction were more frequently in patients with MSA. The stridor was specific to MSA. Improvement in motor scores in the levodopa test was higher in patients with PD (PD: 39.7 %; MSA: 17.89; p = 0.019).

DISCUSSION

Sympathetic response to postural changes, description of symptoms of autonomic dysfunction, and motor response to levodopa test are useful tools in order to improve specificity of the diagnostic criteria of PD and MSA. The GH test with apomorphine was not useful for a differential diagnosis.

Ventajas y peculiaridades del abordaje laparoscópico en el anciano

Both the age of the population and anesthetic and surgical techniques are advancing. Currently, 40% of surgical activity is performed in patients older than 65 years, who present a higher surgical risk than younger patients. The aim of treatment in the elderly is to provide the best possible quality of life, even though this represents a surgical challenge because of associated comorbidity and reduced cardiopulmonary reserve. From the moment at which laparotomy becomes an increased stress in the elderly, laparoscopic surgery can be particularly advantageous in this population. Therefore, minimally invasive surgery may have a greater impact in these individuals than in younger patients in reducing postoperative pain, cardiorespiratory complications, hospital stay, and recovery time before resuming physical activity. The recent advances in anesthesia, together with improved patient selection and perioperative cardiac care, and the general adoption of minimally invasive access have enabled more complex gastrointestinal procedures to be performed in the elderly. The factors that could influence the development of this type of approach in the elderly, as well as the precautions that should be taken, should be further analyzed.

The validity and reliability of the global index of safety (GIS)

OBJECTIVE

The global index of safety (GIS) is an adverse event (AE) based instrument designed to evaluate the safety profile of drugs. This paper presents the evaluation of the inter-rater reliability and validity of a 94-item GIS for antipsychotics through Rasch analysis.

RESEARCH DESIGN AND METHODS

A total of 194 psychiatrists participating in an outpatient pharmacoepidemiologic study of olanzapine in schizophrenia rated the severity that each AE would have on a 5-point scale. Reliability was determined through a paired comparison design involving the new independent ratings of 101 different psychiatrists participating in another study of olanzapine in acute inpatient units. Spearman's, Pearson's and Intra-class correlation (ICC) coefficients were used to estimate the inter-rater reliability of the AE weights. Validity was analyzed through the Rasch rating scale model.

RESULTS

Reliability coefficient estimates were excellent (Spearman = 0.99, Pearson = 0.99, ICC = 0.98), supporting the inter-rater reliability of the item weights. Through goodness-of-fit statistics and the investigation of the hierarchy of item calibrations, Rasch analysis confirmed the validity of the instrument.

CONCLUSION

The data presented here on inter-rater reliability estimates of adverse events related to antipsychotic drugs indicate that GIS is a promising alternative for the evaluation of the safety profile of drugs.

Psychometric validation of a generic health-related quality of life measure (EQ-5D) in a sample of schizophrenic patients

OBJECTIVE

The aim of this study was to evaluate the construct validity of a generic health related quality of life (HRQOL) instrument - the EQ-5D - in a sample of schizophrenic patients receiving antipsychotic treatment.

RESEARCH DESIGN AND METHODS

A total of 2128 schizophrenic patients treated with olanzapine, 417 treated with risperidone, and 112 with haloperidol responded to the EQ-5D. The study also assessed the effect of patient age, gender, and co-morbidity variables on patient's HRQOL Main outcomes measures: EQ-5D scores at the start of treatment and after 3 and 6 months of therapy were compared with results from the Clinical Global Impression (CGI) severity of illness scale and the (GAF) scale. The effect of antipsychotics and sociodemographic variables on patient's HRQOL over time was tested through a three-factor doubly multivariate repeated measures MANCOVA.

RESULTS

High scores in the GAF scale and low scores in the CGI were linked with high scores on the EQ-5D scale. The correlational effects observed between the EQ-5D and the clinical indices ranged from 0.33 to 0.54. A significant effect of 'visit time' as well as an interaction of 'visit time' x drug, 'visit time' x gender, and 'visit time' x co-morbidity was observed.

CONCLUSIONS

Results suggest the EQ-5D is a valid instrument capable of detecting HRQOL differences between schizophrenic patients with different degrees of severity of illness.

[Bilateral subthalamic nucleus deep-brain stimulation (STN-DBS) in Parkinson's disease: initial experience in Cruces Hospital]

INTRODUCTION

Clinical outcomes of Parkinson's disease patients treated for 12 months with STN-DBS were analyzed. PATIENTS ADN METHODS: Twelve patients were selected using the CAPSIT protocol criteria and placement of electrodes in the appropriate target was performed according to results of fusion image techniques and intraoperative microrecording.

RESULTS

A reduction in motor UPDRS (44 %) and activities of daily living (58 %) scores during <<off>> phases were observed. <<On>> time with dyskinesias was reduced (86 %), while severe dyskinesias disappeared. Levodopa dosage was also lowered (44 %). Patients and caregivers showed a clear-cut benefit on quality of life (58 % and 61 % respectively). No cognitive deterioration was observed and morbidity was in the same range as that published by other teams.

CONCLUSION

Bilateral STN-DBS is an effective symptomatic therapy for complicated Parkinsońs disease patients. It improves the quality of life of patients and their caregivers and allows a reduction of levodopa dosage.

[Neuropsychological changes and bilateral subthalamic deep brain stimulation in Parkinson's disease]

INTRODUCTION

To investigate neuropsychiatric changes in Parkinson's disease (PD) patients after 12 months of bilateral subthalamic deep brain stimulation (DBS-STN).

SUBJECTS

Nine out of 23 patients with PD subjected to DBS-STN were included. The mean follow-up of this cohort was 12 months, mean disease duration 14.2 5.5 years and mean UPDRS motor score in <<off>> 43.2 13.7.

METHODS

Patients were selected on the basis of CAPSIT criteria. They underwent bilateral implant of stimulators in STN under stereotactic conditions. Quality of life scale (PDQ 39), depression scale (Brev-Cet), frontal function test (Stroop, Wisconsin, verbal fluency) and memory evaluation (Barcelona test) were monitored at baseline in <<on>> medication and after 12 months in <<on>> medication/<<on>> stimulation.

RESULTS

The patients' motor scores improved on an average of 40.2 % (p = 0.0002) in <<off>> medication situation and 58 % in quality of life scores. We observed a benefit in depression scores (52 %, p = 0.003). Immediate verbal memory improved as well, 25 % (p = 0.04) in recall memory and 14 % (p = 0.02) in recognition memory. No changes were observed in visual memory, verbal fluency and/or global cognitive tests.

CONCLUSION

DBS-STN in PD patients seems to be an effective tool for improving their quality of life, due to its benefits on motor function, verbal memory and mood. Bilateral DBS-STN did not affect either verbal fluency or executive functions in our patients. Neuropsychological assessment is a good tool for selection and study of the operated patients.

Treatment of severely psychotic inpatients with schizophrenia: olanzapine versus other antipsychotic drugs

Nine hundred and ten schizophrenic inpatients suffering from acute psychotic episodes were included in a naturalistic study. Patients were prescribed treatment with olanzapine (OLZ) or with typical antipsychotic (TYP) drugs. Patients receiving another atypical antipsychotic were excluded. Of the whole sample, 483 (53.4%) were treated with olanzapine and 421 (46.6%) with typical antipsychotics. Three specific subpopulations of greater severity were defined: patients with prominent psychotic symptoms, agitated patients, and patients initially treated with intramuscular (i.m.) medication because of their acute clinical condition. Severity of illness was assessed using the Clinical Global Impression (CGI) scale for severity, the Brief Psychiatric Rating Scale (BPRS) and the Nursing Observational Scale for Inpatient Evaluation. Baseline differences were adjusted per data analysis. The mean change from baseline to endpoint of overall symptomatology (total BPRS score) was significantly greater in the olanzapine group compared to the typical antipsychotic-treated group, both in the sample of patients with prominent positive symptoms (P < 0.001) and in the sample of agitated patients (P =0.015). Significant differences were also found in BPRS positive scores, BPRS negative scores and CGI scores in these two populations. Patients who had received previous i.m. drugs showed no statistically significant differences in symptomatic improvement between both treatments groups, except for a more favourable response of BPRS negative subscores in the olanzapine group (P =0.015). The results suggest that olanzapine may be considered as a first line treatment for severely psychotic inpatients with schizophrenia.

Global index of safety (GIS): a new instrument to assess drug safety

There is an asymmetry between the extraordinary development of measures and tools aimed at studying the beneficial effects of the drugs and the more limited methods to assess their safety profile. The goal of our study was to develop a global measuring tool to assess drugs' safety. We conducted a survey of Spanish psychiatrists in mental health centers and outpatient treatment units to assess the severity scores that they would assign to a list of the most common adverse events (AEs) that usually occur with antipsychotic treatment. The severity scores were then applied to the list of AEs that really occurred along a naturalistic pharmacoepidemiological study on the use of different antipsychotics in the treatment of schizophrenia. The Global Index of Safety (GIS) of the experimental group treated with olanzapine (OLZ) was compared with the GIS of the control group and with the GIS of specific antipsychotics for which the number of treated patients was greater than 100. A total of 194 psychiatrists rated the severity of each AE on a scale of 1 (insignificant) to 5 (extremely severe). The individual severity was applied to the 2949 schizophrenic patients included in a pharmacoepidemiological study. A GIS was calculated for every group of patients receiving the same treatments. The GIS of the control group was higher (4.3) than that calculated from the experimental group (2.5) (P < 0.001). The GIS of the risperidone (3.6) and haloperidol (6.0) subgroups were higher than that calculated from the OLZ group (P < 0.001). The development of a GIS may facilitate the comparison of the safety of several drugs and may constitute a very valuable aid for those involved in selecting drugs.

Comparison of older and newer neuroleptics for the treatment of schizophrenia

This article reviews the current antipsychotic treatments available for schizophrenia. After a review of its history - from the beginning of last century - emphasis is placed on the distinguishing features of the new antipsychotic therapies against typical neuroleptic agents. An attempt is made to relate the different mechanisms of antipsychotic events in these groups of drugs with their efficacy and safety profiles before going on to develop more extensively the prospects provided by new antipsychotic drugs in the areas of acute clinical efficacy and maintenance, safety and quality of life for the schizophrenic patient.

Double-blind olanzapine vs. haloperidol D2 dopamine receptor blockade in schizophrenic patients: a baseline-endpoint

The aim of this study was to compare in vivo striatal D2 dopamine receptor occupancy induced by olanzapine and haloperidol in schizophrenic patients using a baseline-endpoint [(123)I]IBZM single photon computed emission tomography (SPECT) design. The relationships of striatal D2 receptor occupancy with clinical efficacy and extrapyramidal symptoms (EPS) were also assessed. Twenty-seven inpatients with schizophrenia or schizophreniform disorder were included in a 4-week prospective, randomized, double-blind, parallel and comparative clinical trial. Thirteen patients were treated with haloperidol (10 mg/day) and 14 with olanzapine (10 mg/day). Ratings of clinical status and EPS were obtained weekly. The percentage of D2 receptor occupancy was estimated by using basal ganglia (striatum)/frontal cortex IBZM uptake ratios obtained from each patient before and after 4 weeks of maintained antipsychotic treatment. Olanzapine led to a mean striatal D2 receptor occupancy of 49% (range 28-69%), which was significantly lower than that induced by haloperidol (mean 64%, range 46-90%). The baseline-endpoint SPECT design used in this study revealed lower antipsychotic D2 occupancy percentage values than those reported in the literature, using other approaches. The degree of striatal D2 receptor occupancy correlated to the EPS, which predominantly appeared in patients on haloperidol. No relationship was found between the striatal D2 receptor occupancy and clinical improvement. Olanzapine induced a lower striatal D2 occupancy than haloperidol. This low striatal D2 occupancy, together with the lower incidence of EPS in olanzapine-treated patients, contributed to confirm the atypical behavior of this new antipsychotic drug. Nevertheless, conclusions based on SPECT-estimated percentages of antipsychotic D2 occupancy should be cautious, since the SPECT design could influence the results. In this regard, SPECT studies including baseline and endpoint examinations should be encouraged.

[Incidence of extrapyramidal symptoms during treatment with olanzapine, haloperidol and risperidone: results of an observational study]

OBJECTIVES

To analyze the incidence of extrapyramidal symptoms (EPS) and the concomitant use of anticholinergic drugs in outpatients diagnosed of schizophrenia treated with olanzapine (OLZ) in comparison with haloperidol (HAL) and risperidone (RIS) under routine clinical practice conditions.

MATERIAL AND METHODS

The analysis was carried out on the basis of the information obtained in the EFESO study, an observational, prospective study carried out in outpatients diagnosed of schizophrenia and treated with olanzapine compared to other antipsychotic agents used in the clinical practice. The incidence of EPS in the OLZ treated group compared to the haloperidol and risperidone treatment groups in which over 100 patients were included is analyzed in the present work. The study duration was 6 months and the data were collected by 293 psychiatrists from mental health care areas.

RESULTS

The percentage of patients who presented at least one adverse event (AE) (p 3/4 0.001) was less in the OLZ groups (47.8%) compared to those of the HAL (79.8%) and RIS (57.2%) subgroups. A lower percentage of patients treated with OLZ (36.9%) presented EPS in comparison to the RIS (49.6%) and HAL (76%) subgroups (p 3/4 0.001). A lower rate of patients from the OLZ group (10.2%) received anticholinergic treatments compared to the RIS (19.9%) and HAL (44%) subgroups (p< 0.001 in both cases).

CONCLUSIONS

OLZ-treated patients presented a lower incidence of EPS and required less anticholinergic treatment than the HAL and RIS treated patients. These results, obtained in naturalistic conditions, coincide with the conclusions reached in randomized clinical trials carried out prior to the marketing of OLZ.

Evidence of chromosome instability in chronic pancreatitis

In the current study we analyzed chromosome instability on peripheral blood lymphocytes cultured from 7 untreated patients with chronic pancreatitis (CP) by assessing telomeric associations (TAS), chromosome aberrations (CA) and sister chromatid exchanges (SCE). Seven healthy individuals were also analyzed. Mean frequencies of TAS were significantly higher in CP patients (X +/- SE: 11.00 +/- 2.37) compared to controls (1.00 +/- 0.30) (p<0.001). Chromosomes preferentially involved in TAS were: 9, 20, 16 and 21, being the most affected arms: 9p, 20q, 16p, 9q and 21q. All these terminal bands were coincident with cancer breakpoints (p<0.03), two of them (40%) were specifically associated to pancreatic carcinoma rearrangements. Three bands (60%) were coincident with oncogene location. The mean frequency of CA was significantly higher in patients (3.88 +/- 0.80) compared to controls (0.63 +/- 0.49) (p<0.001). Chromosomes 1, 2 and 13 were the most damaged. No specifically affected breakpoints were found. SCE analysis showed higher levels in patients (8.33 +/- 0.70) than in controls (6.62 +/- 0.34) (p<0.025), but no differences were observed in cell cycle kinetics. Our results clearly indicate that CP patients exhibit chromosome instability, showing the presence of an unstable genome that could be related to the cancer development observed in this disease.

High frequencies of telomeric associations, chromosome aberrations, and sister chromatid exchanges in ulcerative colitis

OBJECTIVE

Chromosome instability provides a predisposing background to malignancy, contributing to the crucial genetic changes in multistep carcinogenesis. The aim of this work was to analyze chromosome instability in patients with ulcerative colitis (UC) to achieve a better understanding of the increased risk for colorectal cancer.

METHODS

Peripheral blood lymphocyte cultures from 20 untreated UC patients and 24 controls were used to study chromosome instability by assessing telomeric associations (TAS), chromosome aberrations (CA), and sister chromatid exchanges (SCE).

RESULTS

Mean frequencies of TAS and CA were significantly increased in UC patients compared to controls (p < 0.001). Chromosomes 10, 11, 21, 16, and 19 were the most frequently involved in TAS. A total of 104 CA clustered in 66 breakpoints could be exactly localized. Seven nonrandom bands significantly affected in UC patients were found (p < 0.004), showing a significant correlation with the location of cancer breakpoints (p < 0.003), particularly with colorectal carcinoma rearrangements. SCE analysis showed higher levels in patients compared to controls (p < 0.006), but no differences were observed in cell cycle kinetics.

CONCLUSIONS

Our results demonstrate the presence of an unstable genome in UC patients that could be related to the cancer development observed in this disease.

Clinical application of amniotic membranes on a patient with epidermolysis bullosa

The case of a patient with dystrophic epidermolysis bullosa treated with radiosterilised amniotic membranes is presented. The disorder is a congenital disease characterised by a poor desmosomal junction in the keratinocyte membrane. After proper donor screening, amnios were collected at Hospital Central Sur de Alta Especialidad (HCSAE), PEMEX and microbiological analysis was performed at Universidad Nacional Autónoma de México, FQUNAM, (Biology Dept. of the Chemistry Faculty, National Autonomous University of Mexico), before and after radiation sterilisation. Processing, packaging and sterilisation were performed at Instituto Nacional de Investigaciones Nucleares, ININ, (National Nuclear Research Institute). The patient, a ten-year-old boy with severe malnutrition, extensive loss of skin and pseudomonad infection in the whole body, was treated with gentle debridement in a Hubbard bath. Later amnion application was performed with sterilised amnios by using two different processes, in one of which the amnion was sterilised with paracetic acid, preserved in glycerol, kindly donated by the German Institute for Tissue and Cell Replacement and applied by Dr. Johannes C. Bruck, IAEA visiting expert, and the other amnion was processed at ININ: air dried and sterilised by gamma radiation at dose of 30 kGy. After spontaneous epithelisation was successfully promoted for seven days, the pain was alleviated and mobility was improved in a few hours and the patient's general condition was so improved that in a month he was discharged. Unfortunately, because this disease is revertive and has malignant degeneration, the prognosis is not good.

Results of a home-based training program for patients with COPD

OBJECTIVES

To have a group of COPD patients undergo a simple program of home-based exercise training, using the shuttle walking test (SWT) to standardize the intensity of training.

METHODS

Sixty patients participated, randomly distributed into two groups (rehabilitation and control) of 30 patients each. The following evaluations were carried out at baseline and at 12 weeks: (1) pulmonary function studies; (2) SWT; (3) submaximal intensity resistance test; (4) cycle ergometer test; (5) quality of life; and (6) dyspnea. The rehabilitation group underwent a lower-extremity training program. Walking was selected as the type of exercise. The intensity of training was set at 70% of the maximum speed attained on the SWT. Divided sessions were held, lasting 1 h, 6 days/wk, at home, with a checkup every 2 weeks. The duration of the program was 12 weeks.

RESULTS

The following patients completed the study: 20 patients (66.6%) from the rehabilitation group (mean [+/- SD]) age, 64.3 +/- 8.3 years; mean FEV(1), 41.7 +/- 15.6% of predicted); and 17 patients (56.6%) from the control group (mean age, 63.1 +/- 6.9 years; mean FEV(1), 40 +/- 16.4% of predicted). We found no changes in pulmonary function or effort parameters (SWT or cycle ergometer) in the rehabilitation group at 12 weeks. A twofold increase (1,274 +/- 980 to 2,651 +/- 2,056 m; p < 0.001) was achieved in the submaximal intensity resistance test, with less dyspnea at the conclusion of the test (p = 0.05). Significant improvement also was achieved in basal dyspnea and, both statistically and clinically, in the quality of life. Significant changes were not achieved in the control group patients.

CONCLUSIONS

A simple home-based program of exercise training achieved improvement in exercise tolerance, posteffort dyspnea, basal dyspnea, and quality of life in COPD patients.

Doses of olanzapine, risperidone, and haloperidol used in clinical practice: results of a prospective pharmacoepidemiologic study. EFESO Study Group. Estudio Farmacoepidemiologico en la Esquizofrenia con Olanzapina

OBJECTIVE

The objectives of this study were to determine the doses of olanzapine (OLZ), risperidone (RIS), and haloperidol (HAL) used in clinical practice in outpatients with schizophrenia and the rates of occurrence of extrapyramidal symptoms (EPS) and other adverse events, clinical response, and use of concomitant medications.

METHODS

The present study involved a subset of patients from a 6-month, open-label, prospective observational study. Data were collected by 293 psychiatrists at mental health centers and other outpatient treatment facilities in Spain. Medications and doses used, occurrence of EPS and other adverse events, and scores on the Clinical Global Impression (CGI) of Severity Scale and Global Assessment of Function (GAF) were recorded. Clinical response was defined as a decrease of > or = 2 points on the CGI, with a final CGI score < or = 4.

RESULTS

A total of 2657 patients were included in the analysis. The initial and overall mean daily doses for the 3 groups were as follows: OLZ, 12.2 and 13.0 mg, respectively; RIS, 5.2 and 5.4 mg; and HAL, 13.9 and 13.6 mg. Initial and overall median daily doses were the same in each group: OLZ, 10 mg; RIS, 6 mg; and HAL, 10 mg. A significantly lower proportion of OLZ-treated patients (36.9%) experienced EPS compared with RIS-treated (49.6%) and HAL-treated (76.0%) patients (P < or = 0.001). A significantly lower proportion of patients in the OLZ group (47.8%) experienced adverse events compared with patients in the RIS (57.2%) and HAL (79.8%) groups (P < or = 0.001). A significantly greater proportion of OLZ-treated patients (37.3%) were responders compared with RIS-treated patients (31.5%) (P < 0.05). In all 3 groups, patients who had an initial CGI score > or = 5 received significantly higher overall mean daily doses than did patients with an initial CGI score < 5 (P < 0.001). A significantly lower proportion of OLZ-treated patients (10.2%) were receiving concomitant anticholinergic medication at the end of the study (month 6) compared with RIS-treated (19.9%) and HAL-treated (44.0%) patients (P < 0.001).

CONCLUSION

The mean daily doses recorded in this analysis based on data from a naturalistic setting are consistent with recommendations based on clinical trials. Compared with both RIS- and HAL-treated patients, OLZ-treated patients were less likely to experience EPS or other adverse events, and less likely to use concomitant anticholinergic medications. OLZ-treated patients were also more likely to respond to treatment than were RIS-treated patients.

The safety of olanzapine compared with other antipsychotic drugs: results of an observational prospective study in patients with schizophrenia (EFESO Study). Pharmacoepidemiologic Study of Olanzapine in Schizophrenia

INTRODUCTION

Results of controlled clinical trials should be confirmed through safety and effectiveness studies in nonselected patient cohorts treated according to routine clinical practice.

METHOD

Outpatients with schizophrenia (ICD-10 criteria) entered this prospective, naturalistic study when they received a new prescription for an antipsychotic drug. Treatment assignment was based on purely clinical criteria, as the study did not include any experimental intervention. Safety was evaluated through the collection of spontaneous adverse events and a specific questionnaire for extrapyramidal symptoms. Global clinical status was measured through the Clinical Global Impressions-Severity (CGI-S) and the Global Assessment of Functioning (GAF) scales.

RESULTS

From the 2967 patients included, 2128 patients were treated with olanzapine as monotherapy or combined with other drugs (olanzapine group), and 821 were treated with other antipsychotic drugs as monotherapy or combined with other drugs (control group). There were no statistical differences between treatment groups at baseline regarding age, gender, disease duration, or severity of symptoms. Olanzapine was well tolerated and effective in this study. Overall incidence of adverse events was significantly lower in the olanzapine group compared with the control group (p < .001). Somnolence and weight gain were significantly more frequent in the olanzapine group, and akathisia, dystonia, extrapyramidal syndrome, hypertonia, hypokinesia, and tremor were significantly higher in the control group. Clinical improvement at endpoint, measured through the mean change in the CGI-S and the GAF, was significantly higher in the olanzapine group compared with the control group (p = .004).

CONCLUSION

These results show that olanzapine is safe and effective in nonselected schizophrenic outpatients and are consistent with the efficacy and safety profile that olanzapine has shown in previous controlled clinical trials.

Modification of dopamine D2 receptor activity by pergolide in Parkinson's disease: an in vivo study by PET

It is well known that chronic administration of pergolide and other dopamine agonists may induce a downregulation of dopamine D2 receptors in the rat model of Parkinson's disease (PD). To our knowledge, this effect has not been demonstrated in vivo in patients with PD. At present, the status of striatal dopamine D2 receptors can be studied with use of positron emission tomographic (PET) technology. Five patients with PD chronically treated with levodopa were studied with use of PET and [11C]-raclopride before and after 6 months of pergolide treatment (dose range = 4.5-7.5 mg/d). We found a slight reduction in the specific striatal [11C]-raclopride uptake index (mean reduction 14% in putamen and 9% in caudate) after pergolide treatment. This reduction appears to be related to downregulation of the receptor, although competitive binding of pergolide at the D2 receptor cannot be excluded.

Olanzapine in treatment-refractory schizophrenia: results of an open-label study. The Spanish Group for the Study of Olanzapine in Treatment-Refractory Schizophrenia

BACKGROUND

Clozapine is currently the treatment of choice for neuroleptic-resistant schizophrenia. Olanzapine is a new antipsychotic drug that has shown efficacy against positive and negative symptoms of schizophrenia, with minimal extrapyramidal side effects. However, the effectiveness of olanzapine has not yet been reported among treatment-refractory schizophrenic patients.

METHOD

A total of 25 schizophrenic patients (DSM-IV criteria) with documented lack of response to two conventional antipsychotic drugs entered this 6-week prospective, open-label treatment trial with olanzapine 15 to 25 mg/day. An optional extension up to 6 months was provided.

RESULTS

As a group, the olanzapine-treated patients showed statistically significant improvement (p < .05) in both positive and negative symptoms by the end of 6 weeks of therapy. Overall, 9 of the patients (36%) met the a priori criteria for treatment-response (> or = 35% decrease in Brief Psychiatric Rating Scale [BPRS] total score, plus posttreatment Clinical Global Impression-Severity < or = 3 or BPRS total < 18). Only one patient discontinued treatment because of an adverse event during the study. Despite the relatively high dosages of olanzapine used, there were no reports of parkinsonism, akathisia, or dystonia, and no patients required anticholinergic medication.

CONCLUSION

This open study suggests that olanzapine may be effective and well tolerated for a substantial number of neuroleptic-resistant schizophrenic patients. Further blinded, controlled trials are needed to confirm our results.

[Cost effectiveness analysis of olanzapine versus haloperidol in the treatment of schizophrenia++ in Spain]

BACKGROUND

Cost-effectiveness of olanzapine in comparison with haloperidol, in Spanish schizophrenic patients, was analysed using a clinical decision model.

METHODS

The model represents a simulation of the different clinical and therapeutic possibilities that an hypothetical cohort of patients could experienced in a 5-years period of treatment. Efficacy was measured as months with partial-complete remission. Most information was obtained from the HGAJ randomised clinical trial. Other information was estimated through literature reviews and the opinion of an expert panel.

RESULTS

Average cost-effectiveness for olanzapine was lower (116,476 pesetas per month with partial-complete remission) than for haloperidol (134,762 pesetas per month with partial-complete remission). Olanzapine produced more than half year (6.7 months) with partial complete remission, in comparison with haloperidol, with antincrementar cost-effectiveness of 32,516 pesetas per month with partial-complete remission, in comparison with haloperidol. The results were not sensitive to changes in the values of the main variables used in the analysis.

CONCLUSIONS

According to this analysis, olanzapine presents a good cost-effectiveness relationship in comparison with baloperidol, in Spanish schizophrenic patients. The analysis will be completed when new studies comparing olanzapine with other antipsychotics are available.

[Complete axonotmesis of the axillary nerve in relation to microtrauma]

INTRODUCTION

The axillary nerve is injured in many clinical situations, mainly in major surgical or traumatic lesions of the shoulder. Equally, it may be found in the context of microtraumatisms or compressive mechanisms. Amyotrophic neuralgia is a clinical entity with pain and later atrophy of the muscle which affects various nerves and nerve groups, as shown by neurophysiological studies.

CASE REPORT

We present a lesion with complete axonotmesis of the axillary nerve with a time-relationship to microtraumatism. Initially the patient complained of some pain in the shoulder. During follow-up striking atrophy of the deltoid muscle was seen.

CONCLUSIONS

We have reviewed the mechanisms described for lesions of the axillary nerve, which do not include the one we found. We discuss the possibility of our case being included in the clinical group described as having amyotrophic neuralgia, although there are some neurophysiological findings which are not typical of this condition. We suggest a review of the many possible trigger factors described in the genesis of amyotrophic neuralgia. Possibly some cases with atypical histories of trauma, and lesions shown by neurophysiological studies to be particularly severe, may be separated from this group.

Chromosome instability in untreated adult celiac disease patients

Spontaneous chromosome aberrations (CAs) and induced fragile sites (FSs) were analysed in 12 untreated adult coeliac disease (CD) patients and 8 healthy controls. Blood lymphocytes from each individual were cultured for 72 h at 37 degrees C in F-10 medium with 5% fetal calf serum and 0.1 ml phytohemagglutinine. FSs were induced by FudR (10 micrograms/ml, 24 h before harvesting) and caffeine (2.2 mM. 6 h before harvest). Spontaneous CAs and FSs were analysed on 30-50 Giemsa-stained and G-banded metaphases. The mean frequencies of spontaneous CAs (abnormal cells, gaps/cell and breaks/cell) of CD patients (0.24 +/- 0.02, 0.21 +/- 0.02 and 0.13 +/- 0.02, respectively) were significantly higher than those of controls (0.04 +/- 0.01, 0.02 +/- 0.01 and 0.02 +/- 0.01, respectively) (p < 0.001). Fourteen spontaneous CAs and 5 FSs specific for CD patients presented a strong coincidence (70%) with bands involved in T- and B-cell malignant lymphoma rearrangements. These findings suggest that CD has chromosome instability affecting specific points that could be related to the high prevalence of malignancies in this disorder.

Treating people as objects, agents, or "subjects": how young children with and without autism make requests

A procedure previously used to investigate imperative communication in non-human primates was applied to young children, some of whom had autism. The goal was to examine closely how requests are made in a problem-solving situation. Each child's spontaneous strategies to obtain an out-of-reach object were analyzed in terms of the ways in which he or she used the adult who was present. Results showed that fewer children with autism used a strategy of treating the person as a "subject", and that more children with autism used object-centred strategies.

Chromosome instability in lymphocytes from patients with celiac disease

Cytogenetic studies were performed in celiac disease (CD) patients to determine if the presence of chromosome instability is related to the predisposition to cancer. Chromosome aberrations (CA) and sister chromatid exchange (SCE) frequencies in peripheral blood lymphocyte cultures from untreated CD patients and healthy controls were analyzed. Patients showed aberrations in 23% of cells, while only 3% were detected in the control group (p < 0.0001). The mean frequencies of gaps, breaks and total CA were found to be higher in CD patients compared to controls (p < 0.0001). Breakpoint distribution was nonrandom among chromosomes from celiac patients (p = 0.01), but not among controls (p = 0.04). The frequency of SCE/cell showed a mean value of 6.9 +/- 0.6 in CD patients and 7.3 +/- 0.2 in controls. No statistical differences were found. Breakpoints involved in CD patients presented a strong coincidence with the location of fragile sites (78.6%) and sites of cancer chromosome rearrangements (57.1%), most of them (75%) associated with malignant non-Hodgkin lymphomas. These results suggest that CD is a condition with increased chromosome instability characterized by a high level of CA and normal SCE frequencies, probably related to the increased incidence of cancer.

The results of surgical treatment of lumbar arachnoiditis

Forty patients with lumbar arachnoiditis, following previous operations, were classified into 4 myelographic types. Most patients with type I images had herniated disc symptoms with unilateral leg pain and limited straight-leg raising. Patients with types II and III myelographic appearances had bilateral leg pain, absent ankle jerks, weakness, cramps and signs of diffuse sensory deficit; some also had neurogenic claudication and urinary sphincter dysfunction. All patients with type IV had dysesthesia. Twenty-three of the 40 patients underwent reoperation and those with types I and II had acceptable results, but poor results occurred in those with types III and IV myelograms.

[Natural history of viral hepatitis A in Chilean adults: clinical and laboratory aspects]

In many countries, Hepatitis is mainly due to virus. A. When improving life condition in a given population, initially there is a tendency to increase the number of cases in adults. We report clinical and laboratory findings in 87 adults with acute viral Hepatitis A in Chile. The rate man/woman was 1.55/1. Mean age: 23.8 years. Clinical forms: icteric classical (77.01%), cholestatic (10.34%), anicteric (8.05%), biphasic (2.30%) and fulminant (2.30%). From 87 patients in consult 1, 64 were controlled at day 15 (consult 2) and 35 one year later (consult 3). Laboratory (means): ALT (UI/L): 856.8, 111.6 and 20.8 in consult 1, 2 and 3 respectively. Correlation between values of ALT and AST (p < 0.0001). Mean total bilirubin (mg%): 6.6, 2.5 and 0.8 respectively. The evolution of Hepatitis A was favorable with a rapid decrease of clinical signs and normalization of laboratory values within the 3 first weeks of disease.

Increased rDNA transcriptional activity in celiac disease

The activity of nucleolar organizer regions (NORs) in chromosomes of peripheral blood lymphocyte cultures from 20 healthy subjects and 32 patients with celiac disease (CD) (nine untreated patients, nine treated but with dietary lapses, and 14 treated with gluten-free diet (GFD) and normal small bowel histology) was studied. Furthermore, three female patients diagnosed with small bowel non-Hodgkin's lymphoma (NHL) complicating CD were studied. Silver (Ag)-staining technique was used to visualize positive NORs. In each individual, 20 metaphases were analyzed to determine the number of NORs per cell. The average of Ag-NOR+ per cell, expressed as mean +/- SD, was found to be higher in the CD group (6.62 +/- 0.65) compared with controls (5.70 +/- 0.81) (p less than 0.001). This increase was evident in both groups of chromosomes analyzed (D and G). No differences were found among the three groups, but all of them were found to be statistically different compared to controls (p less than 0.001). The NHL complicating CD patients showed a statistically increased frequency of Ag-NORs (7.20 +/- 0.39) with respect to CD patients (p less than 0.02) and controls (p less than 0.001). These findings show an increase of the transcriptional activity of rDNA in CD that could be related to the high incidence of malignancy in this pathology. Longitudinal studies of CD patients should be performed to confirm this evidence.

[Post-transfusion hepatitis iin Chile: the reference parameters]

Most cases of post-transfusion hepatitis correspond to infection by non-A non-B virus. Indirect test (ALT elevation, anti-HBc titers) have been used to detect the presence of this virus. We screened 692 blood donors and health personnel, measuring anti-HBc (n = 572), HBs antigen (340), and ALT serum levels (190). Positive results were obtained for anti-HBc in 1.7% and HBs in 0%. ALT levels were 25 +/- 12 u/l in males and 18 +/- 14 in females (p < 0.01). ALT levels above 45 u/l were found in 6% of subjects. ALT levels were not related to anti-HBc positiveness nor to alcohol intake. The possible risk of posttransfusion hepatitis related to increased ALT levels remains to be clarified by specific markers.

Enzymatic assays: optimization of systems by using pyruvate kinase and lactate dehydrogenase as auxiliary enzymes

A method to optimize enzymatic assays by using pyruvate kinase and lactate dehydrogenase enzymes is presented and applied to mitochondrial ATPase as an example. Optimum amounts of auxiliary enzymes, to obtain either a 99% of the initial rate in a given time (t99) or a given lag period (L), are calculated from their apparent Michaelis constants (Kapp) in the medium used and their prices per enzymatic international unit.

Complex phosphoglycerides from rat liver outer mitochondrial membranes

The ethanolic extract from rat liver mitochondrial membranes contains a number of highly polar complex lipids, which are found in the aqueous layer when subjected to the usual chloroform-water partition procedures. Two of these lipids have been purified by thin-layer chromatography, and their structures partially elucidated. Apparently, both are derivatives of phosphatidylglycerol, with a bulky polar head containing sugars and aminoacids. They are specifically located in the outer membrane. Several structures are suggested, as well as a possible functional rôle for these compounds.

Aminoacid composition and hydrophobicity index of mitochondrial polypeptides

The aminoacid composition of protein stained bands in polyacrylamide gels, after electrophoresis of proteins from inner mitochondrial membranes, was investigated hydrolyzing directly the gel slices. The Hydrophobicity Index of 18 prominent polypeptide bands was calculated after their aminoacid analysis. The polypeptides less related to the membrane have low hydrophobicity as inferred from their Hydrophobicity Indexes.

Highly polar non-glycerol containing lipids present in our mitochondrial membranes

Aqueous 80% ethanol extracts from the outer mitochondrial membranes contained a series of compounds, insoluble in chloroform-methanol (2:1) and soluble in chloroform-methanol-water (10:10:3). These compounds contain fatty acids, amino acids and hexoses. Procedures are described for the extraction, purification and cromatographic separation of these compounds. Five of them have been partially characterised. Some structural data are given. It is suggested that some relationship could exist with the glycosylation of the outer membrane proteins.

An index of protein hydrophobicity. Its application to membrane proteins

A hydrophobicity index is proposed for proteins. The calculation of this index is made, assuming a direct relationship between the hydrophobicity of each aminoacid and its Rf in a partition chromatography. This index is applied to membrane proteins and offers statistically significant differences between integral and peripheral proteins.

Protein distribution is submitochondrial particles after lipid peroxidation

Three fractions of submitochondrial particles were isolated by differential centrifugation of mitochondrial inner membranes incubated with 1 mM ascorbate. Proteins were separated by polyacrylamide gel electrophoresis and their pattern was found to be different for the three fractions. These results are in agreement with previous work which showed the dissimilar enzyme distribution and chemical composition of these submitochondrial particles and pointed out the heterogeneity of the inner mitochondrial membrane.