Clozapine in elderly psychiatric patients: tolerability, safety, and efficacy.

Psychotic disorders in the elderly are frequent, of multiple etiologies, and little researched. With the advent of "atypical" neuroleptics, their role in treating elderly psychiatric patients needs to be investigated. Clozapine is widely used; however, its use is common in the elderly whose psychosis is a feature of neurological morbidity (Parkinson's disease, dementia, etc.), making it difficult to ascertain the safety, tolerability, and efficacy in psychiatric disorders in late life. The aim of the present review is to evaluate clozapine's effect in elderly psychiatric patients with no neurological comorbidity. A computerized literature search (MedLine 1966 to 1997) revealed 133 patients fulfilling said criteria. Fifteen patients had side effects and/or adverse events during treatment; nine of these were receiving a dosage greater than 100 mg clozapine daily. In 19 patients, treatment was discontinued, three due to noncompliance and 16 due to side effects. In seven patients, leukopenia/agranulocytosis was reported. The majority of side effects (27 of 34) and treatment discontinuations were within the first 90 days of treatment. Although efficacy is difficult to compare across studies because of differing methods of evaluation, the great majority of patients showed moderate to marked improvement of psychotic features. The reported effectiveness in patients able to continue treatment for extended periods is significant. Thus, clozapine at a relatively low mean dose (134 mg daily) seems to be safe, tolerated, and effective in elderly psychiatric patients. Agranulocytosis is more frequent than in younger adults and should be monitored carefully.     

Beyond guidelines: promoting clinical change in the real world

There is widespread recognition that simply publishing research findings is not enough to ensure that they are carried into clinical practice. One response to this has been the burgeoning "guidelines movement" of recent years, which has now reached the stage of generating guidelines for the production of guidelines. Argues that guidelines, and other forms of intervention to change clinical practice in an evidence-based direction, will succeed only to the extent that they engage actively with the real world of clinical decision making. This world is more complex than guidelines writers acknowledge, and includes economic, administrative, professional and personal incentives as well as those provided by research evidence. Engaging with this real world may be difficult, but it opens up new possibilities for understanding how clinicians act and how evidence may be used to inform clinical practice. Such possibilities include social influences, educational outreach, providing information to patients, negotiating local coalitions on specific issues and changing the administrative environment.     

Local anaesthetic injection with and without corticosteroids for subacromial impingement syndrome

Fifty patients with impingement syndrome refractory to long-term conservative treatment were randomized to three treatment groups. All patients received an injection of 10 ml 0.5% bupivacaine, in group 1 without corticosteroid, in group 2 with crystalline corticosteroid and in group 3 with lipoid corticosteroid. Treatment in group 1 had to be stopped because of inefficacy. In groups 2 and 3 favorable results were achieved in 19 out of 40 patients.

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Résumé  50 patients avec conflit sous-aeromial, qui ne montraient pas d’amélioration après un long traitement conservatif récevaient une injection dans la bourse subacromiale. Le premier groupe récevait une injection contenant un anaesthétique local pur, groupe 2 une mixture d’anaesthétique avec des corticostéroides cristalins et groupe 3 avec des corticostéroides lipoides. Le traitement du groupe 1 devait être arrété cause d’inificacité. 19 de 40 patients du groupe 2 et 3 montraient une amélioration après 6 mois.

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Accepted: 6 January 2000     

高效液相色谱法对淫羊藿及人参复方产品的定性定量分析

目的　建立一种快速有效的分析方法 ,达到鉴定淫羊藿及人参复方产品中黄酮苷类及人参皂苷类成分 ,并测定各成分含量的目的 ,最终控制复方中淫羊藿及人参的比例。方法　通过反相液相色谱 ,对包括药典所收载的淫羊藿药材及其产品进行分析。淫羊藿中的主要黄酮苷类成分 ,以淫羊藿定A、淫羊藿定B、淫羊藿定C、淫羊藿苷为对照品 ;对主要的人参皂苷类成分 ,以人参皂苷Rg1 、Re、Rf、Rb1 、Rb2 、Rd为对照品。结果　在同一色谱条件下 ,对主要黄酮苷类及人参皂苷类成分均可同时测定且分离良好。结论　该方法适用于淫羊藿、人参及其复方产品中淫羊藿黄酮苷类、人参皂苷类成分的定性、定量分析     

A descriptive analysis of STD prevalence among urban pregnant African-American teens: data from a pilot study.

OBJECTIVE: To assess the prevalence of sexually transmitted diseases (STDs) among a sample of African-American adolescent females at the time of their first prenatal visit and to assess key characteristics of those testing positive for sexually transmitted diseases. The study also determined differences in these characteristics between adolescents who were and those who were not diagnosed with an STD. METHODS: One-hundred-and-seventy pregnant African-American adolescents (aged 14-20 years; mean = 17.5 years) receiving their first prenatal visit were recruited at a prenatal clinic located in a large urban hospital. Biological assessment included nucleic acid amplification testing for gonococcal, chlamydial, and trichomonal infections. Rapid plasma reagin testing assessed infection with syphilis. A self-administered survey and in-depth face-to-face interview were used to collect detailed information assessing adolescents' sociodemographic characteristics, psychosocial indices, and their recent sexual risk behaviors. Data were analyzed using Student's t-tests and contingency table analyses, respectively, for continuous and categorical variables. RESULTS: Overall, 23.5% tested positive for one of the four STDs. Thirteen percent were infected with Chlamydia trachomatis, 1.2% with Neisseria gonorrhoeae, 8.9% with Trichomonas vaginalis, and 1.2% with Treponema pallidum. More than one-half reported recent (past 6 months) treatment for an STD, 30% of these tested positive for at least one of the four STDs assessed. Adolescents testing positive for STDs held favorable attitudes toward condom use, but levels of sexual risk were generally high. There were no sociodemographic, psychosocial, and sexual-risk differences between those testing positive and negative. CONCLUSION: Findings support STD screening efforts targeting pregnant adolescents. Providing clinic-based counseling and prevention education programs to pregnant adolescents regardless of apparent risk factors may also be warranted.     

Detection of pharyngeal perforation: comparison of aqueous and barium-containing contrast agents

OBJECTIVE: We sought to assess the value of aqueous and barium-containing contrast agents in the detection of pharyngeal perforation. SUBJECTS AND METHODS: Visual and objective in vitro comparisons of an iodinated aqueous contrast agent, a 50% weight/volume barium suspension, and a 100% weight/volume barium suspension were performed. Moreover, to exclude pharyngeal perforation after surgery, we prospectively examined 109 patients by pharyngography, using the aqueous contrast agent and the 100% weight/volume barium suspension. All patients with a pharyngeal perforation were followed up clinically to exclude complications due to barium application. RESULTS: As opposed to the 100% weight/volume barium suspension, in vitro comparison between the aqueous contrast agent and the 50% weight/volume barium suspension yielded no substantial differences. Seventeen perforations could be detected with the aqueous contrast agent. Although 10 of 17 perforations could be slightly better visualized with the 100% weight/volume barium suspension, two perforations were missed with this agent. Five perforations were equally well detected with both. CONCLUSION: Because of a higher radiopacity, 100% weight/volume barium suspensions may more sharply delineate perforations. However, in contrast to aqueous contrast media, narrow pharyngeal perforations can be missed. Thus, the use of a 100% weight/volume barium suspension does not improve the detection of pharyngeal perforation.     

Renin-angiotensin system blockade prevents the increase in plasma transforming growth factor beta 1, and reduces proteinuria and kidney hypertrophy in the streptozotocin-diabetic rat.

INTRODUCTION: Combination therapy with angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) is used to improve renal outcome achieved by monotherapy in diabetic patients. In addition, interference with the renin-angiotensin system (RAS) reduced expression and excretion of transforming growth factor beta 1 (TGF-beta 1) in diabetic nephropathy. The aim of this study was to investigate the effects of interrupting the RAS by ACE inhibitor (ACE-I) or ARB monotherapy or by combination therapy on proteinuria, kidney hypertrophy and plasma TGF-beta 1 in diabetic rats. MATERIALS AND METHODS: Forty-one male Wistar rats were allocated to five groups: 1 = control rats, 2 = diabetic rats (streptozotocin [STZ] 55 mg/kg), 3 = diabetic rats as above receiving enalapril (20 mg/kg/day), 4 = diabetic rats receiving losartan (80 mg/kg/day), 5 = diabetic rats receiving both losartan and enalapril. The study lasted 60 days. RESULTS: Urinary protein excretion, kidney weight, serum ACE activity and plasma TGF-beta1 increased significantly in untreated diabetic rats compared with controls. Administration of losartan, enalapril, or both for 60 days prevented these changes. Furthermore, combined therapy for 30 days normalised urinary protein excretion, while monotherapy did not. Losartan inhibited serum ACE activity both in vivo and in vitro. Plasma TGF-beta 1 levels were positively correlated with blood glucose levels (r=0.4059) and with urinary protein excretion (r=0.3558). CONCLUSIONS: Combination therapy with losartan and enalapril was more effective than monotherapy with either drug in achieving an early antiproteinuric response. Long-term treatment with losartan was as effective as the combined treatment, possibly due to a dual inhibitory effect on the RAS. The antiproteinuric effect may be related, in part, to reduced TGF-beta 1.     

Bone Tissue Composition in Postmenopausal Women Varies With Glycemic Control From Normal Glucose Tolerance to Type 2 Diabetes Mellitus

The risk of fragility fracture increases for people with type 2 diabetes mellitus (T2DM), even after controlling for bone mineral density, body mass index, visual impairment, and falls. We hypothesize that progressive glycemic derangement alters microscale bone tissue composition. We used Fourier-transform infrared (FTIR) imaging to analyze the composition of iliac crest biopsies from cohorts of postmenopausal women characterized by oral glucose tolerance testing: normal glucose tolerance (NGT; n = 35, age = 65 ± 7 years, HbA1c = 5.8 ± 0.3%), impaired glucose tolerance (IGT; n = 26, age = 64 ± 5 years, HbA1c = 6.0 ± 0.4%), and overt T2DM on insulin (n = 25, age = 64 ± 6 years, HbA1c = 9.13 ± 0.6). The distributions of cortical bone mineral content had greater mean values (+7%) and were narrower (−10%) in T2DM versus NGT groups (p < 0.05). The distributions of acid phosphate, an indicator of new mineral, were narrower in cortical T2DM versus NGT and IGT groups (−14% and −14%, respectively) and in trabecular NGT and IGT versus T2DM groups (−11% and −10%, respectively) (all p < 0.05). The distributions of crystallinity were wider in cortical NGT versus T2DM groups (+16%) and in trabecular NGT versus T2DM groups (+14%) (all p < 0.05). Additionally, bone turnover was lower in T2DM versus NGT groups (P1NP: −25%, CTx: −30%, ucOC: −24%). Serum pentosidine was similar across groups. The FTIR compositional and biochemical marker values of the IGT group typically fell between the NGT and T2DM group values, although the differences were not always statistically significant. In summary, worsening glycemic control was associated with greater mineral content and narrower distributions of acid phosphate, an indicator of new mineral, which together are consistent with observations of lower turnover; however, wider distributions of mineral crystallinity were also observed. A more mineralized, less heterogeneous tissue may affect tissue-level mechanical properties and in turn degrade macroscale skeletal integrity. In conclusion, these data are the first evidence of progressive alteration of bone tissue composition with worsening glycemic control in humans. © 2020 American Society for Bone and Mineral Research (ASBMR).