1-[2-[(Heteroaryloxy)heteroaryl]carbamoyl]indolines: novel and selective 5-HT2C receptor inverse agonists with potential as antidepressant/anxiolytic agents

Bisaryl ethers have been identified with excellent 5-HT2C affinity and selectivity over both 5-HT2A and 5-HT2B receptors. Compounds such as 11, 27 and 38 have potent oral activity in a centrally mediated pharmacodynamic model of 5-HT2C function and their potential as novel non-sedating anxiolytic and antidepressants is under investigation.

1-[2-[(Heteroarylmethoxy)aryl]carbamoyl]indolines are selective and orally active 5-HT2C receptor inverse agonists

Bisarylmethoxyethers have been identified with nanomolar 5-HT2C affinity and selectivity over both 5-HT2A and 5-HT2B receptors. Compounds such as 1, 2, 8, 12, 14 and 18 have potent oral activity in a centrally mediated pharmacodynamic model of 5-HT2C function and their therapeutic potential is currently under further investigation.

Cognitive-behavioral group therapy versus phenelzine in social phobia: long-term outcome

To evaluate the effects of maintenance treatment and durability of gains after treatment discontinuation, responders to either phenelzine (PZ) or cognitive-behavioral group therapy (CBGT) from an acute trial comparing these two treatments as well as pill placebo and a psychotherapy control (educational supportive group therapy) were enrolled into maintenance and treatment-free follow-up phases.

EXPERIMENTAL DESIGN

Responders to an acute trial contrasting PZ and CBGT entered a six-month maintenance phase. Patients who continued to respond through the maintenance phase entered a six-month treatment free phase. Patients receiving pill placebo or educational supportive group therapy in the acute trial did not enter the long term study.

PRINCIPAL OBSERVATIONS

PZ patients entered maintenance more improved than CBGT patients, and nonrelapsing PZ patients maintained their superior gains throughout the study. Relapse during maintenance did not differ between treatments. However, PZ patients showed a trend toward greater relapse during treatment-free follow-up. There was a greater relapse among patients with generalized social phobia with phenelzine.

CONCLUSIONS

PZ and cognitive-behavioral group therapy may differ in their long term effects. The superiority seen with PZ on some measures in the acute study persisted in patients who maintained their gains over the course of maintenance and treatment-free follow-up. However, CBGT may lead to a greater likelihood of maintaining response after treatment has terminated. Replication with larger samples is needed, as is a study of the acute and long-term efficacy of combined PZ and CBGT.

Photodamage to human RPE cells by A2-E, a retinoid component of lipofuscin

PURPOSE

A fluorescent component of lipofuscin, A2-E (N-retinylidene-N-retinylethanol-amine) has been shown to impair lysosomal function and to increase the intralysosomal pH of human retinal pigment epithelial (RPE) cells. In addition to its lysosomotropic properties A2-E is known to be photoreactive. The purpose of this study was to determine the phototoxic potential of A2-E on RPE cells.

METHODS

A2-E (synthesized by coupling all-trans-retinaldehyde to ethanolamine) was complexed to low-density lipoprotein (LDL) to allow for specific loading of the lysosomal compartment. Human RPE cell cultures were loaded with the A2-E-LDL complex four times within 2 weeks. A2-E accumulation was confirmed by fluorescence microscopy and flow cytometry analysis. Acridine orange staining allowed assessment of lysosomal integrity and intralysosomal pH. The phototoxic properties of A2-E were determined by exposing A2-E-free and A2-E-fed RPE cell cultures to short wavelength visible light (400-500 nm) and assessing cell viability and lysosomal integrity.

RESULTS

Fluorescence microscopy and flow cytometry analysis demonstrated that the intralysosomal accumulation of A2-E in cultured RPE cells increased with the number of feedings. Acridine orange staining confirmed that the A2-E was located in the lysosomal compartment and induced an elevation of intralysosomal pH. Exposure of A2-E-fed cells to light resulted in a significant loss of cell viability by 72 hours, which was not observed in either RPE cells maintained in the dark or A2-E-free cultures exposed to light. Toxicity was associated with a loss of lysosomal integrity.

CONCLUSIONS

A2-E is detrimental to RPE cell function by a variety of mechanisms: inhibition of lysosomal degradative capacity, loss of membrane integrity, and phototoxicity. Such mechanisms could contribute to retinal aging as well as retinal diseases associated with excessive lipofuscin accumulation-for example, age-related macular degeneration and Stargardt's disease.

Ataque de nervios and history of childhood trauma

Ataque de nervios is a common, self-labeled Hispanic folk diagnosis. It typically describes episodic, dramatic outbursts of negative emotion in response to a stressor, sometimes involving destructive behavior. Dissociation and affective dysregulation during such episodes suggested a link to childhood trauma. We therefore assessed psychiatric diagnoses, history of ataque, and childhood trauma in treatment-seeking Hispanic outpatients (N = 70). Significantly more subjects with an anxiety or affective disorder plus ataque reported a history of physical abuse, sexual abuse, and/or or a substance-abusing caretaker than those with psychiatric disorder but no ataque. In some Hispanic individuals, ataque may represent a culturally sanctioned expression of extreme affect dysregulation associated with childhood trauma. Patients with ataque de nervios should receive a thorough traumatic history assessment.

Dose-response relationships for hepatic aflatoxin B1-DNA adduct formation in the rat in vivo and in vitro: the use of immunoslot blotting for adduct quantitation

An immunoslot blotting (ISB) method for quantitating aflatoxin B1-DNA adduct levels has been developed and used to examine the relationship between dose and hepatic aflatoxin B1-DNA adduct levels in rats fed aflatoxin B1 (AFB1) in the diet at dose levels of between 0.5 and 10 micrograms/kg/day. The method has also been used to examine the dose-response relationship for adduct formation in precision-cut rat liver slices incubated with AFB1 at concentrations between 0.01 and 2 microM. For the feeding studies, groups of male Fisher F344 rats were given AFB1 in the diet for periods of 1 to 10 weeks and hepatic DNA adduct levels determined using ISB. The time for adduct levels to reach steady-state conditions was determined in animals given approximately 10 micrograms of AFB1/kg/day and steady-state levels at lower concentrations measured. The time course for the accumulation of AFB1-DNA adducts in rat liver slices incubated with AFB1 at 0.5 microM has been investigated and the relationship between adduct formation and AFB1 concentration over a wide concentration range in liver slices has been determined.

DNA adducts produced by oils, oil fractions and polycyclic aromatic hydrocarbons in relation to repair processes and skin carcinogenesis

Ten polycyclic aromatic hydrocarbons (PAHs) mainly with three or four aromatic rings were tested for their ability to induce DNA adduct formation in mouse skin. Four of these were selected to investigate adduct formation and loss over a period of 8 days. Three mineral oils were also examined for their adduct forming ability and one was selected for adduct formation and loss over a period of 8 days. In addition, fractions derived from the same oil containing 2-3- and 4-6-ring aromatic compounds were applied to mouse skin in a non-carcinogenic oil vehicle and adduct levels were observed over an 8-day period. It was found that PAHs that had no mutagenic, initiating or carcinogenic activity and those that had mutagenic activity in bacteria but no initiating activity in mouse skin failed to produce DNA adducts in mouse skin. Two of the three PAHs with initiating activity and both complete carcinogens produced clear evidence of adduct formation, the adduct levels produced by complete carcinogens being 100-1000 times greater than those produced by initiators. Examination of adduct formation and loss with the carcinogenic PAHs benzo[a]pyrene and 5-methylchrysene over an 8-day period showed a peak at 24 h and an apparent two-phase process of adduct loss. It is suggested that the first steep loss was due to DNA repair and that the more gradual subsequent loss was probably due to epidermal hyperplasia and desquamation. With the initiator 1, 4-dimethylphenanthrene (three rings) a peak of adduct formation was seen at 2 days and adduct levels were not reduced much by 8 days. This suggested that, with initiators, adduct formation and repair may be spread over a longer period than with complete carcinogens. With the whole oils, clear evidence of adduct formation was seen with both a carcinogenic non-solvent-refined oil and with a non-carcinogenic residual oil. The level of adduct formation with the residual oil, however, was much lower than with the carcinogenic oil. When adduct formation by the carcinogenic oil was examined over 8 days, the pattern of adduct formation and loss was similar to that of a tumour initiator rather than a complete carcinogen. Peak adduct levels on the diagonal of the thin-layer chromatography (TLC) plates seemed to occur at 1 and 4 days after treatment, with no clear reduction after 8 days. From examination of adducts formed by the 2-3-ring and 4-6-ring aromatic fractions, it appeared that the main adduct spots produced by the carcinogenic oil were due to the 2-3-ring aromatic components of the oil. Adduct spots near the vertical axis of the TLC plates were also seen with the 2-3-ring and 4-6-ring fractions. The relevance of these spots is uncertain, but if they truly represent adducts, the findings suggest that they are due mainly to 4-ring PAHs. The studies suggest that the activity of carcinogenic oils is largely due to substituted 3- and 4-ring polycyclic aromatic compounds and that more attention should be paid to substituted 3-ring compounds in predicting the carcinogenic potential of oils from analytical data.

Care of foot ulcers in the diabetic patient

Practice profiles are reflective pieces written by nurses in practice, and based on continuing professional development articles. This week Sian Davies discusses diabetic foot ulcers.

Ciprofibrate therapy improves endothelial function and reduces postprandial lipemia and oxidative stress in type 2 diabetes mellitus

BACKGROUND

Exaggerated postprandial lipemia (PPL) is a factor in atherogenesis, involving endothelial dysfunction and enhanced oxidative stress. We examined the effect of ciprofibrate therapy on these parameters in type 2 diabetes mellitus.

METHODS AND RESULTS

Twenty patients entered a 3-month, double-blind, placebo-controlled study. Each subject was studied fasting and after a fatty meal, at baseline, and after 3 months of treatment. Glucose and lipid profiles were measured over an 8-hour postprandial period. Endothelial function (flow-mediated endothelium-dependent vasodilatation [FMD]) and oxidative stress (electron paramagnetic resonance spectroscopy) were measured after fasting and 4 hours postprandially. At baseline, both groups exhibited similar PPL and deterioration in endothelial function. After ciprofibrate, fasting and postprandial FMD values were significantly higher (from 3.8+/-1. 8% and 1.8+/-1.3% to 4.8+/-1.1% and 3.4+/-1.1%; P<0.05). This was mirrored by a fall in fasting and postprandial triglycerides (3. 1+/-2.1 and 6.6+/-4.1 mmol/L to 1.5+/-0.8 and 2.8+/-1.3 mmol/L, P<0. 05). Fasting and postprandial HDL cholesterol was also elevated (0. 9+/-0.1 and 0.8+/-0.1 mmol/L and 1.2+/-0.2 and 1.2+/-0.1 mmol/L, P<0. 05). There were no changes in total or LDL cholesterol. Fasting and postprandial triglyceride enrichment of all lipoproteins was attenuated, with cholesterol depletion of VLDL and enrichment of HDL. There were similar postprandial increases in oxidative stress in both groups at baseline, which was significantly attenuated by ciprofibrate (0.3+/-0.6 versus 1.5+/-1.1 U, P<0.05).

CONCLUSIONS

This study demonstrates that fibrate therapy improves fasting and postprandial endothelial function in type 2 diabetes. Attenuation of PPL and the associated oxidative stress, with increased HDL cholesterol levels, may be important.

Reality orientation for dementia: a systematic review of the evidence of effectiveness from randomized controlled trials

The effectiveness of classroom reality orientation (RO) in dementia was evaluated by conducting a systematic literature review. This yielded 43 studies, of which 6 were randomized controlled trials meeting the inclusion criteria (containing 125 subjects.) Results were subjected to meta-analysis. Effects on cognition and behavior were significant in favor of treatment (cognition standardized mean difference [SMD] = -0.59; 95% confidence interval [CI] -0.95(-)-0.22; behavior SMD = -0.64, 95% CI = -1.20(-)-0.08). The evidence indicates that RO has benefits on both cognition and behavior for dementia sufferers. However, a continued program may be needed to sustain potential benefits. Future research should evaluate RO in well-designed multicenter trials.

Biarylcarbamoylindolines are novel and selective 5-HT(2C) receptor inverse agonists: identification of 5-methyl-1-[[2-[(2-methyl-3-pyridyl)oxy]- 5-pyridyl]carbamoyl]-6-trifluoromethylindoline (SB-243213) as a potential antidepressant/anxiolytic agent

The evolution, synthesis, and biological activity of a novel series of 5-HT(2C) receptor inverse agonists are reported. Biarylcarbamoylindolines have been identified with excellent 5-HT(2C) affinity and selectivity over 5-HT(2A) receptors. In addition, (pyridyloxypyridyl)carbamoylindolines have been discovered with additional selectivity over the closely related 5-HT(2B) receptor. Compounds from this series are inverse agonists at the human cloned 5-HT(2C) receptor, completely abolishing basal activity in a functional assay. The new series have reduced P450 inhibitory liability compared to a previously described series of 1-(3-pyridylcarbamoyl)indolines (Bromidge et al. J. Med. Chem. 1998, 41, 1598) from which they evolved. Compounds from this series showed excellent oral activity in a rat mCPP hypolocomotion model and in animal models of anxiety. On the basis of their favorable biological profile, 32 (SB-228357) and 40 (SB-243213) have been selected for further evaluation to determine their therapeutic potential for the treatment of CNS disorders such as depression and anxiety.

The health status of diabetic patients receiving orthotic therapy

Diabetes has a major impact on the quality of life and those with related foot ulcers are among those most affected. The main aim of the study, which was carried out over an 18-month time period, was to compare the self-reported health status of a group of diabetic patients receiving orthotic therapy with that of other groups who did not receive the therapy. A sample of 280 was recruited from patients with type I and type II diabetes. The study group comprised four groups of patients: those receiving orthotic therapy (insoles) for pedal complications as a result of their diabetes; those with diabetes mellitus, without complications of the disease affecting their foot; those with unilateral lower limb amputation and those with active ulceration who had not been prescribed footwear. The specialised orthotic intervention resulted in statistically significant improvements in health status (p < 0.05), (measured using the SF-36) both physically and mentally, for patients with at-risk feet and should become an integral part of the treatment regime for diabetics with at-risk feet.

Attempting to set up a randomised controlled trial

AIM

The aim of this article is to provide an account of an attempt to set up a randomised control trial (RCT) to evaluate the effects of programmes of continuing professional education on nursing practice.

METHOD

The logistical and methodological challenges of the RCT are described, and an alternative quasi-experimental approach is outlined.

RESULTS

It was not possible to obtain a sample of potential students due to the many constraints put on managers, mainly in relation to maintaining staff morale and providing a service while staff are away on courses.

CONCLUSION

Few studies into the effects of education on nursing practice adopt a randomised control trial (RCT) methodology. Most continue to be process rather than outcome oriented, focusing on such things as teaching and learning strategies. This might be related to the methodological challenges posed by the RCT when applied in social settings.

Bioscience in the pre-registration curriculum: finding the right teaching strategy

With the transition of pre-registration nursing programmes into higher education, a disproportionate number of problems have arisen in relation to the bioscience component of the curriculum. Therefore, a survey was undertaken to obtain the views of students (n = 294) and staff (n = 57) to identify effective teaching strategies to facilitate students' learning and understanding of this difficult area of the curriculum. In contrast to the staff, the majority of students found all three teaching strategies (lectures, tutorials and laboratory sessions) of approximately equal value to their learning and practice. Our findings suggest that students' problems with the biosciences could be ameliorated by adjustments in curriculum apportionment. Our data would support the continuation of lead lectures and laboratory work in bioscience. However, a tutorial system, specifically designed to overcome the particular difficulties experienced by nursing students in this area, is needed. This should augment, not replace, lectures and teaching laboratories. There was little indication that such a redistribution of resources would be favoured by the majority of the staff.

Increases in intrahepatic CD68 positive cells, MAC387 positive cells, and proinflammatory cytokines (particularly interleukin 18) in chronic hepatitis C infection

BACKGROUND

Upregulation of Th1 associated intrahepatic cytokines in chronic hepatitis C virus (HCV) infection should lead to a significant non-specific cellular immune response, a prerequisite for viral clearance. However, to date, the role of this non-specific response in HCV has been understudied.

AIMS

To analyse the intrahepatic macrophage activity in chronic HCV infection by immunostaining and by quantitation of cytokine mRNA.

METHODS

HCV positive liver tissues (chronic hepatitis, n=10; cirrhosis, n=5) were immunostained for CD68, MAC387, and semiquantitated by polymerase chain reaction for intrahepatic cytokine mRNAs (interferon gamma (IFNgamma), interleukin 1beta (IL-1beta), IL-6, IL-18, tumour necrosis factor alpha (TNFalpha), and macrophage inflammatory protein 1beta (MIP1beta)). HCV negative normal liver tissues (for cytokines, n=6; for immunostaining, n=5) were included as controls.

RESULTS

MAC387(+) cells were focally increased in areas of erosion at the limiting plate while lobular staining was minimal. CD68(+) staining was diffuse in both portal (increased in HCV) and lobular areas. The portal tract (mean) density of CD68(+) and MAC387(+) cells was significantly increased in patients with HCV compared with normal tissue. IFNgamma and IL-18 mRNA levels were highly correlated and significantly upregulated in chronic hepatitis and cirrhotic tissue versus controls. TNFalpha mRNA was upregulated in chronic hepatitis without cirrhosis, while IL-6 mRNA was significantly downregulated. IL-1beta, IL-6, and MIP1beta mRNA levels were significantly correlated with portal tract MAC387(+) cell density.

CONCLUSIONS

The significant upregulation of IFNgamma and IL-18 mRNA and significant correlations between IFNgamma and other proinflammatory cytokines, suggest a Th1/cell mediated intrahepatic immune response in chronic HCV infection. However, further clarification of the cellular sources of these cytokines is required.

Reality orientation for dementia

BACKGROUND

Reality Orientation (RO) was first described as a technique to improve the quality of life of confused elderly people, although its origins lie in an attempt to rehabilitate severely disturbed war veterans, not in geriatric work. It operates through the presentation of orientation information (eg time, place and person-related) which is thought to provide the person with a greater understanding of their surroundings, possibly resulting in an improved sense of control and self-esteem. There has been criticism of RO in clinical practice, with some fear that it has been applied in a mechanical fashion and has been insensitive to the needs of the individual. There is also a suggestion that constant relearning of material can actually contribute to mood and self-esteem problems. There is often little consistent application of psychological therapies in dementia services, so a systematic review of the available evidence is important in order to identify the effectiveness of the different therapies. Subsequently, guidelines for their use can be made on a sound evidence base.

OBJECTIVES

To assess the evidence of effectiveness for the use of Reality Orientation (RO) as a classroom-based therapy on elderly persons with dementia.

SEARCH STRATEGY

Computerised databases were searched independently by 2 reviewers entering the terms 'Reality Orientation, dementia, control, trial or study'. Relevant websites were searched and some handsearching was conducted by the reviewer. Specialists in the field were approached for undocumented material, and all publications found were searched for additional references.

SELECTION CRITERIA

All randomised controlled trials (RCTs), and all controlled trials with some degree of concealment, blinding or control for bias (second order evidence) of Reality Orientation as an intervention for dementia were included. The criteria for inclusion/exclusion involved systematic assessment of the quality of study design and the risk of bias, using a standard data extraction form. A measure of cognitive and/or behavioural change was needed.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by both reviewers, using a previously tested data extraction form. Authors were contacted for data not provided in the papers. Psychological scales measuring cognitive and behavioural changes were examined.

MAIN RESULTS

6 RCTs were entered in the analysis, with a total of 125 subjects (67 in experimental groups, 58 in control groups). Results were divided into 2 subsections: cognition and behaviour. Change in cognitive and behavioural outcomes showed a significant effect in favour of treatment.

REVIEWER'S CONCLUSIONS

There is some evidence that RO has benefits on both cognition and behaviour for dementia sufferers. Further research could examine which features of RO are particularly effective. It is unclear how far the benefits of RO extend after the end of treatment, but and it appears that a continued programme may be needed to sustain potential benefits.

Promoting autonomy and independence for older people within nursing practice: an observational study

Although autonomy and independence are widely held to be important goals of care for older people, these terms lack precise definition and operationalization in the literature. This paper reports on observational data gathered as part of an evaluation of educational programmes in the nursing care of older people. Strategies which appear both to promote and inhibit autonomy and independence of older patients in a range of care settings are described. Recommendations are made for further research to explore the extent to which autonomy and independence are appropriate goals of care for older people with cognitive impairment.

Reminiscence therapy for dementia

BACKGROUND

Reminiscence Therapy (RT) has been defined as vocal or silent recall of events in a person's life, either alone, or with another person or group of people. It typically involves group meetings, at least once a week. in which participants are encouraged to talk about past events, often assisted by aids such as photos, music, objects and videos of the past. There is, often, little consistent application of psychological therapies in dementia services. A number of these 'therapies' were greeted with enthusiasm by health care practitioners in understimulating care environments. They were expected to work miracles and their 'failure' to do this has led to their widespread disuse. A systematic review of the available evidence is important in order to identify the effectiveness of the different therapies. Subsequently, guidelines for their use can be made on a sound evidence base.

OBJECTIVES

RT involves groups of elderly people talking of past events, assisted by aids such as videos, pictures and archives, as a means of communicating and reflecting upon their life experiences. The objective of the review is to assess the effects of RT for dementia.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register, MEDLINE, PSYCHLIT, EMBASE, OMNI, BIDS, Dissertation Abstracts International, SIGLE and reference lists of relevant articles up to 1998, and we contacted specialists in the field. We also searched relevant internet sites and we handsearched Aging and Mental Health, the Gerontologist, Journal of Gerontology, Current Opinion in Psychiatry, Current Research in Britain: Social Sciences, British Psychological Society conference proceedings and Reminiscence database.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised trials of RT for dementia in elderly people.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality.

MAIN RESULTS

Two trials are included in the review, but only one trial with 15 participants had extractable data. The results were statistically non-significant for both cognition and behaviour.

REVIEWER'S CONCLUSIONS

No firm conclusions could be reached regarding the effectiveness of RT for dementia. The review highlighted the urgent need for more systematic research in the area.

Neonatal screening for sickle cell disease

BACKGROUND

Sickle cell disease is an inherited disorder that occurs throughout the world with its highest incidence in areas of Africa where malaria is endemic. It affects up to one in 60 infants born in some areas of Africa. There are a number of potentially serious complications associated with the condition, and it is suggested that early treatment (before symptoms develop) can improve both morbidity and mortality. Screening for the condition in the neonatal period would enable early diagnosis and therefore early treatment.

OBJECTIVES

To assess whether there is evidence that neonatal screening for sickle cell disease rather than symptomatic diagnosis reduces adverse short and long term outcomes for those in whom the disease is detected, without adverse outcomes in the population screened.

SEARCH STRATEGY

We searched the Controlled Trials Register of the Cochrane Cystic Fibrosis and Genetic Disorders Group (See Group search strategy). Contact was made with experts in the field for any work as yet unpublished and reference lists of published studies were also searched. Date of the most recent search of the Group's specialised register: November 1999.

SELECTION CRITERIA

Any randomised or pseudorandomised trial, published or unpublished comparing diagnosis by screening to clinical diagnosis would have been considered eligible for inclusion.

DATA COLLECTION AND ANALYSIS

No trials of neonatal screening for sickle cell disease were found.

MAIN RESULTS

No trials of neonatal screening for sickle cell disease were found.

REVIEWER'S CONCLUSIONS

There is a lack of evidence from trials of neonatal screening for sickle cell disease. There is evidence of benefit from early treatment which is made possible by screening and there are a number of reviews and economic analyses of non-trial literature suggesting that screening is appropriate. Health care providers must therefore assess whether the information provided by these documents is relevant to their practice and situation when making decisions regarding neonatal screening for sickle cell disease. Systematic reviews of early treatments/interventions, including penicillin prophylaxis, pneumococcal vaccine and parental education should be considered.