Role of antipsychotics for treating behavioral and psychological symptoms of dementia

Over the past three decades, concerns about the high prevalence of antipsychotic use in the nursing homes (NHs) for the management of behavioral and psychological symptoms of dementia continue to be emphasized and intervened by many. However, despite the numerous side effects and the recent blackbox warning by the United States Food and Drug Administration about the increased risks for stroke and sudden death associated with the use of antipsychotics in dementia, the prevalence of antipsychotic use in NHs remains high. While the use of antipsychotics appeared to have modest efficacy in reducing symptoms of aggression and psychosis in dementia, there is insufficient evidence to routinely recommend the use of alternative psychopharmacological treatments for these symptoms. Hence, clinicians have to balance the safety warnings against the need to treat these symptoms in order to prevent harm to the resident that may result from his/her dangerous behaviors. Although the use of antipsychotics may be warranted in some cases, organizational, resource and training support should be provided to encourage and equip NH staff to participate in interventions so as to minimize inappropriate use of these medicines in NHs. This review will discuss the place in therapy, the trend and appropriateness of antipsychotic use in NHs, as well as the effectiveness of current and future strategies for reducing antipsychotic use in the NHs.

Asthma in pregnancy

Asthma affects approximately 8% of women during pregnancy. Pregnancy results in a variable course for asthma control, likely contributed to by physiological changes affecting the respiratory, immune, and hormonal systems. While asthma during pregnancy has been associated with an increased risk of maternal and fetal complications including malformations, available data also suggest that active asthma management and monitoring can decrease the risk of adverse outcomes. The diagnosis, disease classification, and goals for asthma management in the pregnant woman are the same as for nonpregnant patients. However, evidence shows that pregnant asthmatics are more likely to be undertreated, resulting in asthma exacerbations occurring in approximately one third and hospitalization in one tenth of patients. Pharmacotherapeutic management of asthma exacerbations in pregnant patients follows standard treatment guidelines. In contrast, the principles of asthma maintenance therapy are slightly modified in the pregnant patient. Patients and practitioners may avoid use of asthma medications due to concern for a risk of fetal complications and malformations. A variable amount of information is available regarding the risk of a given asthma medication to cause adverse fetal outcomes, and it is preferable to use an inhaled product. Nevertheless, based on available data, the majority of asthma medications are regarded as safe for use during pregnancy. And, any increased risk to either the mother or fetus from medication use appears to be small compared to that associated with poor asthma control.

Natural isothiocyanates of the genus Capparis as potential agonists of apoptosis and antitumor agents: Mechanisms and implications

In this editorial, we comment on a recent publication, which highlights the important findings from the study, including the antitumor and anti-inflammatory effects of isothiocyanates, their underlying mechanisms, and implications. Additionally, a related perspective is discussed.

Innovate combination of sevoflurane dilution in dimethyl sulfoxide: A stability study by gas chromatography and nuclear magnetic resonance

AIM

To investigate physicochemical stability of sevoflurane in dimethyl sulfoxide using gas chromatography with a flame ionization detector and nuclear magnetic resonance (NMR).

METHODS

Undiluted sevoflurane, plus dilutions 1:2, 1:5, 1:10, 1:25, and 1:50 in dimethyl sulfoxide were prepared in a vertical laminar flow cabinet class II type B and stored at different temperatures (23 °C, 6 °C, and -10 °C) for 45 d. Sterile 1 mL polypropylene amber syringes to minimize light degradation, caps and needles were used. The presence of sevoflurane and its degradation products in the samples was determined by gas chromatography with flame ionization detector (260 °C, 40 min), and by ¹H, ¹⁹F, and proton-decoupled ¹⁹F nuclear magnetic resonance.

RESULTS

The gas chromatography analysis showed sevoflurane and dimethyl sulfoxide (DMSO) retention times were 2.7 and 13.0 min, respectively. Pure DMSO injection into the column resulted in two additional peaks at 2.1 and 2.8 min. The same sevoflurane peak at 2.7 min was observed in all the dilutions at -10 °C, 4 °C and 25 °C. The NMR spectra showed signals consistent with the sevoflurane structure in all the dilutions at -10 °C, 4 °C and 25 °C. In the ¹H spectrum, two signals corresponding to the sevoflurane molecule were observed at 5.12 and 4.16 parts per million (ppm). In the ¹⁹F-NMR spectrum, two signals were observed at chemical shift -76.77 ppm and chemical shift -157.13 ppm. In the ¹⁹F{¹H}-NMR CPD, two signals were observed at chemical shift -76.77 ppm and chemical shift -157.13 ppm. The first one showed a doublet (J^F-F = 3.1 Hz) which integrated by six fluorine nuclei from the hexafluoro-isopropyl group. The second signal was integrated by a fluorine atom and showed a septuplet (J^F-F = 3.1 Hz).

CONCLUSION

This study shows that different concentrations of sevoflurane in dimethyl sulfoxide retain their chemical composition after exposure to different temperatures for a period of 45 d.

Controversial usages of kratom (Mitragyna speciosa): For good or for evil

Kratom (Mitragyna speciosa) is a plant that grows well in tropical climates such as in Southeast Asia. Traditionally, people discovered it possessed a stimulating effect that relieved tiredness. Furthermore, it contains analgesic and medicinal properties for the treatment of pain, diarrhea, muscle discomfort, and blood pressure and to enhance stamina. Nevertheless, long term or regular consumption of kratom leads to addiction. This is because the main alkaloid of kratom, mitragynine, binds to opioid receptors and exerts a euphoric effect similar to that of morphine, which may lead to death. Due to this reason, kratom has been listed as a regulated substance in many countries including the United States, Thailand, Malaysia, Bhutan, Finland, Lithuania, Denmark, Poland, Sweden, Australia, and Myanmar. Usages of kratom carry two pharmacological effects depending on dosage. Low-dose kratom exerts a stimulating effect that refreshes the user. High-dose kratom exerts sedative effects that can lead to addiction similar to that of morphine. Despite the euphoric effect of kratom, the beneficial values of kratom to human health is indisputable. Therefore, a complete banning of kratom may cause a loss to pharmaceutical industry. Rather, a controlled or selective usage of kratom will be a better choice.

Aryl hydrocarbon receptor as a new therapeutic target for cancer and immune disorders

The aryl hydrocarbon receptor (AhR) was discovered more than three decades ago, and initially was characterized as a transcription factor with a role in xenobiotic metabolism. However, based on subsequent observations that AhR remains active under physiological conditions, exhibits constitutive expression during development, and has a high degree of conservation among species, it was hypothesized that AhR is responsible for functions in addition to its role in detoxification. Correspondingly, recent studies have elucidated novel physiological roles for this ligand-dependent transcription factor that link it to several pathways associated with disease development. In this review, studies are presented that support a role for AhR in cell proliferation, apoptosis, and immune homeostasis, thereby highlighting the therapeutic potential of this receptor for cancer and immune disorders.

Tenofovir induced severe thrombocytopenia

Tenofovir disoproxil fumarate is used in the management of hepatitis B and human immunodeficiency virus infection. We present a 50 years old lady, post liver transplant, who was switched over from entecavir to tenofovir, for management of hepatitis B reactivation. She developed bleeding diathesis and severe thrombocytopenia was detected on investigations. Bone marrow examination showed normocellular marrow with megakaryocytes. Tenofovir was stopped and she was started on intravenous immunoglobulin, followed by steroids. There was improvement in platlet counts. The case highlights a rare side effect of tenofovir therapy.

Roles of cholinergic receptors during attentional modulation of cue detection

Basal forebrain corticopetal cholinergic neurons are known to be necessary for normal attentional processing. Alterations of cholinergic system functioning have been associated with several neuropsychiatric diseases, such as Alzheimer’s disease and schizophrenia, in which attentional dysfunction is thought to be a key contributing factor. Loss of cortical cholinergic inputs impairs performance in attention-demanding tasks. Moreover, measures of acetylcholine with microdialysis and, more recently, of choline with enzyme-coated microelectrodes have begun to elucidate the precise cognitive demands that activate the cholinergic system on distinct time scales. However, the receptor actions following acetylcholine release under attentionally-challenging conditions are only beginning to be understood. The present review is designed to summarize the evidence regarding the actions of acetylcholine at muscarinic and nicotinic receptors under cognitively challenging conditions in order to evaluate the functions mediated by these two different cholinergic receptor classes. Moreover, evidence that supports beneficial effects of muscarinic muscarinic-1 receptor agonists and selective nicotinic receptor subtype agonists for cognitive processing will be discussed. Finally, some challenges and limitations of targeting the cholinergic system for treating cognitive deficits along with future research directions will be mentioned. In conclusion, multiple aspects of cholinergic neurotransmission must be considered when attempting to restore function of this neuromodulatory system.

Therapeutic options and vaccine development in the treatment of leishmaniasis

Early treatment of leishmaniasis is critical to achieve cure, prevent psychological and social distress, and prevent transmission of disease. Untreated Leishmaniasis-cutaneous leishmaniasis, mucocutaneous leishmaniasis and visceral leishmaniasis - results in disfiguring scars and high rates of morbidity and mortality in highly endemic regions of the world. However, cure rates with available therapeutics are limited due to cost, therapeutic toxicity and the growing rate of resistance. New therapeutic targets for medications and vaccine development are under investigation to provide improved healing and efficacy for the treatment of Leishmania spp.

Pharmacological management of neuropathic pain in patients with vestibular schwannomas: Experience of the Atlantic Lateral Skull Base Clinic

Neuropathic pain is chronic pain generated by disorders of the peripheral and central nervous system, including skull base tumours. A skull base tumour can be any type of tumour that forms in the skull base, and this includes vestibular schwannomas which arise from the sheath of the inner ear vestibulocochlear nerve (eighth cranial nerve). Growth of the tumour, surgical resection, and/or stereotactic radiotherapy may result in compression and/or irritation of the fifth cranial nerve (trigeminal nerve) resulting in facial pain and/or numbness. Non-trigeminal afferent input may contribute to the wide constellation of symptoms seen in orofacial pain patients. The purpose of this report was to develop a decision tool to guide the recognition and treatment of neuropathic pain in this specialized population. Recommendations for treatment are based on evidence presented in Canadian and international neuropathic treatment guidelines. Algorithms are included for assessment and treatment of adult patients with agents that are recognized to have analgesic efficacy within the broad context of neuropathic pain.