From high doses of oral rivastigmine to transdermal rivastigmine patches: user experience and satisfaction among caregivers of patients with mild to moderate Alzheimer disease

INTRODUCTION

Rivastigmine, a treatment for mild to moderate Alzheimer disease (AD), is the first cholinesterase inhibitor to be available in the transdermal format. We aim to describe user experience and satisfaction with the rivastigmine patch, as well as any clinical changes perceived in patients.

METHODS

Observational, cross-sectional, multicentre study with 239 investigators and 1851 informal caregivers of patients with mild to moderate AD. Patients were treated with transdermal rivastigmine patches for ≥ 6 months and had previously received high doses of oral rivastigmine.

RESULTS

Mean caregiver age was 59.8±14.4 years and 70.9% were women. They spent 10.0±7.1hours per day providing care and 79.8% lived with the patient. Patch instructions were described as easy to follow by 97.1% of the caregivers and 92.1% of them rated patch application as easy or very easy. The most commonly cited disadvantage was adhesion problems (26.8%). Discontinuation of treatment was due to cutaneous reactions in most cases. Overall, 76.5% of the caregivers were satisfied or very satisfied with transdermal treatment and 77.4% considered that its interference with daily activities was minimal or null. The patch was preferred to oral treatment by 94.3% of caregivers. Clinical Global Impression of Change ratings improved according to 61.3% of the caregivers and 53% of the investigators. Few caregivers reported medication forgetfulness.

CONCLUSIONS

Most caregivers of patients with mild to moderate AD preferred the transdermal format of rivastigmine to the oral format. Caregivers also reported overall satisfaction, ease of use, and reduced impact on daily activities for transdermal rivastigmine format, in addition to patient improvement compared to their condition under the previous treatment.

[Rivastigmine as treatment for patients with mild to moderately severe Alzheimer disease under normal clinical practice conditions. The ENTERPRISE study]

INTRODUCTION

Alzheimer disease (AD) causes progressive cognitive decline leading to loss of independence for activities of daily living; rivastigmine is one of the drugs used for symptomatic management.

OBJECTIVE

To assess the therapeutic use of different pharmaceutical forms of rivastigmine in patients with AD in normal clinical practice.

PATIENTS AND METHODS

Cross-sectional, observational, multi-centre study conducted on patients with mild to moderate AD treated with rivastigmine in Spanish outpatient clinics specialising in Geriatrics, Psychiatry, and Neurology. Data regarding use of oral (OR) and transdermal (TDR) rivastigmine, compliance (degree of adherence), and caregiver satisfaction with treatment were evaluated.

RESULTS

In total, 2252 patients with a mean age of 77.2 years were included; 60.2% were women. AD was moderate to moderately severe in 58.4%. Rivastigmine treatment was started orally in 54.4% of the patients and transdermally in 45.6%; 35.6% of those who started treatment by the OR route switched to TDR. A single dose adjustment was sufficient for 77.5% of patients on TDR treatment vs 11.8% of patients receiving OR treatment. More patients on TDR treatment (80.8% vs. 57.1% on OR treatment) reached the maximum therapeutic dose of rivastigmine and did so in a shorter period of time (51.6 vs 205.8 days). Compliance rates (60.5% vs 47.2%) and caregivers' satisfaction with treatment (89.4% vs 81.9%) were also higher for TDR.

CONCLUSIONS

In normal clinical practice, using the TDR route of administration improves dose titration and drug compliance, allowing more patients to reach the maximum recommended dose of rivastigmine in a shorter time period.

Factors determining when to start levodopa/carbidopa/entacapone treatment in Spanish patients with Parkinson's disease

INTRODUCTION

Several therapeutic options are available for the symptomatic treatment of Parkinson's disease (PD).There is no reliable information about which factors are involved in the choice of treatment.

OBJECTIVE

To identify factors contributing to the decision to start treatment with levodopa/carbidopa/entacapone (LCE) in patients with PD.

PATIENTS AND METHODS

We completed a descriptive cross-sectional retrospective multicentre study of patients with idiopathic PD receiving LCE. Clinical data were collected with special attention to factors that could potentially determine when to initiate treatment with LCE in normal clinical practice.

RESULTS

We studied 1050 patients with a mean age of 71.3±8.7 years (58.2% men). Average time from onset of symptoms to diagnosis was 13.8±12.9 months, with a latency time of 74.5±53.6 months before starting LCE treatment. The most common initial symptoms were tremor (70.6%), reduced dexterity (43.2%) and slowness of movement (41.5%). At the start of LCE treatment, most patients were in Hoehn and Yahr stage 2 (57.5%), with an average rating of 73.4% on the Schwab & England scale. Eight hundred twenty two patients (78.3%) received treatment with other drugs before starting LCE (mean time between starting any PD treatment and starting LCE was 40.5±47.2 months). Clinical factors with a moderate, marked, or crucial effect on the decision to start LCE treatment were bradykinesia (84.7%), daytime rigidity (72.2%), general decline (72.2%), difficulty walking (66.4%), tremor (62.7%), nocturnal rigidity (56.1%), and postural instability (53%). Difficulty performing activities of daily living was the only psychosocial factor identified as having an influence on the decision (84.3%).

CONCLUSIONS

The decision to start patients with idiopathic PD on LCE treatment is mainly determined by motor deficits and disabilities associated with disease progression.

Uniaxial absorbing media: conditions for refraction in the direction of the optical axis

When a plane wave is incident from an isotropic medium into a uniaxial transparent medium so that the ordinary wave propagates in the direction of the optical axis, the extraordinary wave will also propagate in the same direction and with the same refractive index. We will show that this is not the case when the second medium is a uniaxial absorbing material. In this work, we will state a clear and precise interpretation of the meaning of propagation in the direction of the optical axis in the case of uniaxial absorbing media. Assuming that the ordinary wave is refracted in the direction of the optical axis we will analyze the refraction of the extraordinary wave and we will compare it with the case of transparent media. The necessary conditions to have both ordinary and extraordinary waves refracted in the direction of the optical axis will be obtained.

Effect of normobaric hypoxia on the testis in a murine model

High-altitude hypoxia generates spermiogram impairment due to germinal epithelium, Leydig cells, sperm and seminal plasma alterations, but precise mechanisms involved are unknown. The objective of this work was to analyse the effect of normobaric hypoxia on the morphology of testicular interstitium and some associated molecular and hormonal factors. Twenty-four mice were exposed to normobaric hypoxia (8.1% inspired oxygen fraction) during 20 days. The effects on body weight, testicular weight, vascularisation, testosterone, HIF1-α and VEGF were analysed at different periods of exposure and compared to controls. Hypoxic mice had lower body weight than mice kept in normoxia. Testicular weight raised significantly the 1st day, but remained normal during the rest of experiment. Number of blood vessels per field and mean diameter of vessels were higher in hypoxic mice. Plasmatic and testicular testosterone raised during first 24 h of hypoxia, but decreased on the 5th day. Vascular/interstitial ratio (proportion of interstice occupied by blood vessels) duplicated at the end of the experiment. Most substantial early effects of hypoxia were testicular oedema, increase in number and diameter of blood vessels and elevation of plasmatic and testicular testosterone. Normobaric hypoxia generates similar effects to those induced by hypobaric hypoxia.

[Peri-operative management of disease modifying anti-rheumatic drugs: recommendations based on a meta-analysis]

The objective of this paper is make recommendations for the perioperative management of antirheumatic treatment based on the best available evidence. A systematic review was performed including studies in which patients with rheumatic diseases treated with biological and non-biological disease-modifying antirheumatic drugs (DMARDs) had undergone surgery. A total of 5,285 studies were recorded, of which 27 were finally included. These contained information on 5,268 patients and 7,933 surgeries. The majority were women (mean age 55 years) were diagnosed with rheumatoid arthritis, and the most studied drug was methotrexate (MTX). The final recommendations include: maintaining treatment with MTX or leflunomide in the perioperative period in the absence of other risk factors for postoperative complications (Level of Evidence 1c, Grade D recommendation). Biological DMARDs should be temporarily suspended, or the surgery scheduled as far as possible from the last dose, and, if there were other risk factors a space at least two doses (Level of Evidence 2c; Grade D recommendation).

Influence of absorption on the anomalous negative refraction in right-handed uniaxial absorbing dielectric media

In this work we study the anomalous negative refraction when a plane wave is incident from an isotropic medium to a uniaxial absorbing medium. We study the influence of the anisotropy on the refractive indices and the anisotropy on the absorption coefficients in the negative refraction of these materials. Negative refraction can occur for the ordinary and extraordinary waves for a wide range of values of the angle of incidence. The allowed values of the angle of incidence that lead to negative refraction are analyzed in detail as a function of the orientation of the optic axis and the values of the refractive indices and absorption coefficients.

Interface between transparent isotropic and uniaxial absorbing dielectric media: equations for ray tracing and for the direction of propagation

In this work we analyze the propagation of a plane wave that passes from an isotropic transparent medium to a uniaxial absorbing medium. Detailed expressions that give the real directions of propagation of the wave and the energy of the reflected and refracted ordinary and extraordinary waves are obtained. These expressions are valid for every orientation of the optic axis of the uniaxial medium and for every direction of propagation of the incident wave. Expressions are tested in the case of an interface between a transparent and an absorbing isotropic media and for the air-rutile (TiO2) interface. The effect of absorption has been evaluated by comparing the results obtained in rutile with the results obtained in a transparent uniaxial medium with the same real refractive indices. Results are presented for different values of the angle of incidence and the orientation of the plane of incidence.

Should levodopa dose be reduced when switched to stalevo?

The addition of entacapone to levodopa-carbidopa (LC) or the switch from LC to a tablet containing levodopa-carbidopa-entacapone (LCE) improves the wearing-off phenomenon, increases the 'on' time and decreases the 'off' time, but the appearance or exacerbation of dyskinesias is the more frequent side-effect. Thus, a reduction of the total levodopa dosage would be recommended. However, this could result in a lack of efficacy against the wearing-off. We report on the results of a clinical trial conducted to determine the best way in terms of efficacy, tolerability and safety of switching from LC to LCE in patients with Parkinson's disease (PD) and end of dose wearing-off. 39 patients with PD and wearing-off without or with mild dyskinesias were randomly assigned to either a group receiving the same LC dosage or to a group in which the total LC amount was reduced by 15-25%. Four weeks after the change, both groups showed an increase in daily 'on' time and a reduction in the daily time spent in 'off'. Two patients in each group experienced an increase in basal dyskinesias. No differences in clinical assessment between groups were found. Tolerance was excellent. This study suggests that switching from LC to LCE in patients with mild-to-moderate wearing-off can be done safely with or without reducing the total LD amount, but in the clinical setting it would be more practical to keep the dosage of LC unchanged unless severe dyskinesias are present.

Complex unitary vectors for the direction of propagation and for the polarization of electromagnetic waves in uniaxial and absorbing dielectric media

The propagation of inhomogeneous and elliptically polarized plane waves in absorbing uniaxial anisotropic media is described using complex unitary vectors to represent the direction of propagation and the direction of polarization. Detailed expressions for electric displacement, electric field, and magnetic field vectors are obtained for the ordinary and extraordinary waves, and their geometry is discussed. According to the complex direction of propagation, three particular cases are studied: the real case (homogeneous wave), the case perpendicular to the optical axis, and the case coplanar with the optic axis. The case of isotropic media is also analyzed.

[Anesthesia in urology: notes on its history and development in Spain, 1847 to 1950]

This review of the historical course of anesthesia performed in the context of urology in Spain relies on primary sources: doctoral theses, dissertations, published articles, inaugural addresses, conference proceedings, and books belonging to various archives and libraries. We collected a large number of documents relating to urology and of particular interest regarding anesthesia, classified them, and subjected them to critical analysis. This allowed us to carefully follow the development of anesthesia and urology itself, both of which attained notable clinical and scientific importance in Spain. Anesthesia with chloroform and incomplete anesthesia were the norm during the second half of the 19th century. However, during the first half of the 20th century, the most widely used techniques were the application of ether or spinal or local infusions, although epidural and intravenous techniques were also mentioned.

Long-term effectiveness and quality of life improvement in entacapone-treated Parkinson's disease patients: the effects of an early therapeutic intervention

To evaluate the long-term effects of entacapone on both mean daily 'on' time and health-related quality of life (QoL) in patients with Parkinson's disease (PD) experiencing 'end-of-dose' motor fluctuations and the benefits of an early therapeutic intervention. A prospective, multicenter, observational, 12-month study was performed with an initial 3-month intervention phase, consisting of a phone call to half of the patients from randomly selected investigators to assess if dose adjustment was necessary. Effectiveness was determined by home diaries ('on' time), subscales II and III of the Unified Parkinson's Disease Rating Scale (UPDRS), and the Parkinson's Disease Questionnaire (PDQ-8). After 3 months of treatment, 4.0% of the intervention group patients discontinued the study, versus 18.4% in the control group (P < 0.01). The improvement in 'on' time was significantly increased since the 3-month visit (21%, P < 0.0001) until the end of the study (23% at 12 months, P < 0.0001). Entacapone also induced significant reductions in the UPDRS scores for subscales II and III and in the PDQ-8 score. 11.2% of patients experienced at least one adverse reaction. This study confirms the effectiveness of entacapone in reducing motor fluctuations by increasing 'on' time, and in improving QoL of PD patients. An early adjustment of entacapone and levodopa doses reduces the number of treatment discontinuations during the first months of treatment.

Intrahepatic DNA vaccination: unexpected increased resistance against murine cysticercosis induced by non-specific enhanced immunity

Experimental murine cysticercosis caused by Taenia crassiceps has proved to be a useful model with which to test the efficacy of new vaccine candidates and delivery systems against pig cysticercosis. A high level of protection against murine cysticercosis was previously observed by intramuscular or intradermal DNA immunization with the use of the sequence of the recombinant KETc7 antigen cloned in pcDNA3 (pTc-sp7). To determine the effect of KETc7 differential expression in DNA vaccination, KETc7 was cloned in pGEM 11Zf(+) under the control of the tissue-specific regulatory promoter phosphoenolpyruvate carboxykinase (pPc-sp7). A high level of protection was induced by intrahepatic immunization with pPc-sp7, pTc-sp7 and the empty vector in the absence of any specific immunity. The empty vector pGEM 11Zf(+), the plasmid with the highest content of CpG sequences, provided to the most efficient protection. This protection was related to an increased number of splenocytes, enhanced nonspecific splenocyte proliferation, and intensified intrahepatic INF-gamma production. Overall, intrahepatic plasmid CpG-DNA immunization provokes an exacerbated nonspecific immune response that can effectively control Taenia crassiceps cysticercosis.

The effect of soybean soapstock on the quality parameters and fatty acid composition of the hen egg yolk

The effects of increasing proportions of soybean soapstock (SSS) in laying hen diets on egg quality parameters and on the fatty acid (FA) composition of the yolk were studied. One hundred sixty Babcock B-300 x laying hens, 20 wk of age, were allotted to 5 dietary treatments comprising a control diet (D5) with soybean oil at 100% or SSS in proportions of 25% (D1), 50% (D2), 75% (D3), and 100% (D4) replacing the oil source in commercial-type diets throughout the 15-wk laying period. Egg quality parameters were recorded weekly. Four pooled yolks for each treatment were collected at 0, 9, and 15 wk, and their FA profiles were determined. Egg weight, shell thickness, shape index, and Haugh unit were not influenced by dietary treatment. The concentrations of saturated FA (SFA) in yolks were generally kept at a constant level, regardless of the percentage of SSS in the hen diets. Total monounsaturated FA (MUFA) content did not vary over the course of the experiment, except for C14:1. After 15 wk of feeding, the total polyunsaturated FA (PUFA) n-3 increased in yolks of all diets. Among the long-chain PUFA, the percentage of C20:4 (arachidonic acid) was less affected. Inclusion of 100% SSS allowed production of eggs with similar PUFA/SFA and n-6/n-3 ratios when compared with eggs from hens fed D5. As SSS represents one-third of the oil cost, its inclusion in layer diets could represent an important economic benefit.

Prevalence of genotypic resistance in untreated HIV-infected patients

The aims of this retrospective study are to assess the prevalence of primary resistances to antiretroviral drugs, both reverse transcriptase and protease inhibitors in untreated patients from Spain, and to determine their possible association with several epidemiological variables. A total of 148 samples belonging to 145 patients were processed using the genotypic technique VERSANT HIV 1 (LiPA) in order to study the presence of mutations at codons 41, 69, 70, 74, 75, 103, 106, 151, 181, 184 and 215 of the reverse transcriptase gene (VERSANT HIV 1 RT) and at codons 30, 46, 48, 50, 54, 82, 84 and 90 of the protease gene (VERSANT HIV 1 Protease). The patients' epidemiological variables which could be relevant to HIV infection were also analyzed. The successful amplification rate was 77.70% for LiPA RT and 91.21% for LiPA P. In the case of LiPA RT, statistical significance (p < 0.05) was observed when successful amplification was related to viral load level (p < 0.001). Global prevalence of resistance was 20.27%. Mutations in the reverse transcriptase gene were found in eight samples (5.40%). Using LiPA P, mutations were detected in 16.21% of cases, with V82A being the most frequently detected mutation (15/24, 62.50%) in nine samples. The V82A mutation was found alone (66.6%) and it was found together with the I84V mutation in five samples (20.83%). I84V was the second most frequently detected mutation (13/24, 54.16%). No statistical significance was found for any of the epidemiological variables. Due to the problems encountered in a high percentage of samples, the authors concluded that the amplification technique should be improved. The prevalence of resistance detected was around the mean of that found by other authors.

Complex unitary vectors for the direction of propagation and for the polarization of electromagnetic waves in absorbing isotropic media

We introduce a formalism based on complex unitary vectors for the direction of propagation and for the polarization in order to describe in detail the propagation of inhomogeneous plane waves in absorbing isotropic media. We obtain analytic expressions for the displacement vector, the electric field, the magnetic field, and the Poynting vector, and we study their geometry in terms of the geometrical interpretation of the complex directions of propagation inside the material. We introduce a complex coordinate system based on complex unitary vectors, where the description of the polarization states of the field vectors and the Poynting vector becomes simpler. The physical meaning and the interpretation of the mathematical operations involving these complex unitary vectors is provided.

The effects of superior ovarian nerve sectioning on ovulation in the guinea pig

The effects on spontaneous ovulation associated with the unilateral or bilateral sectioning of the superior ovarian nerves (SON) were analyzed in guinea pigs at different time intervals of the estrous cycle. Day 1 of the estrous cycle was defined as the day when the animal presents complete loss of the vaginal membrane (open vagina). Subsequent phases of the cycle were determined by counting the days after Day 1. All animals were autopsied on the fifth day of the estrous cycle after surgery. Sectioning the right, left, or both SONs on day 5 (early luteal phase) resulted in a significant increase in the number of fresh corpora lutea. Ovulation increased significantly when the left SON (L-SON) was sectioned during late follicular phase (day 1) and medium luteal phase (day 8). When surgery was performed on days 1 or 8, neither sectioning the right SON (R-SON) nor sectioning the SON bilaterally had an apparent effect on ovulation rates. Similarly, ovulation rates were not affected when unilateral (right or left) or bilateral sectioning of the SON was performed during late luteal phase two (day 12). Unilateral or bilateral sectioning of the SON performed during the early luteal phase (day 5) was associated with a significant decrease in uterine weight. A comparable effect was observed when the L-SON was sectioned during late follicular phase (day 1), or medium luteal phase (day 8). No effects on uterine weight were observed when unilateral or bilateral sectioning of the SON was performed during late luteal phase. Our results suggest that in the guinea pig the SON modulates ovulation, and that the degree of modulation varies along the estrous cycle. The strongest influence of the SONs on ovulation occurs during early luteal phase, and decrease thereafter, being absent by late luteal phase. In addition, sectioning the left or the right SON caused different responses by the ovaries of adult guinea pigs. This paper discusses the mechanisms by which ovulation increased when the SON was surgically cut.

Factors associated with the evolution of the viral load in individuals with HIV infection

The temporal evolution of the viral load (VL) in a group of patients under clinical care and the identification of individual variables that determined this evolution was studied using a retrospective descriptive study of the VL determinations on 1336 patients between September 1996 and June 2000. During follow-up, patients' VLs increasingly fell below the detection threshold. Those patients who had received antiretroviral treatment prior to the monitoring of the viraemia presented lower VLs at the start of their follow-up. Those patients who had been cared for on the same unit throughout their follow-up maintained lower VLs. Female patients uniformly presented lower VL results than the males. The immunological status at the beginning of follow-up and the basal VL determined the initial evolution of the patients' VL, although it did not do so in the final stages of follow-up. The immunological and virological state at the onset of the follow-up determines the evolution of the patients' VL.