Levetiracetam extended release and levetiracetam immediate release as adjunctive treatment for partial-onset seizures: an indirect comparison of treatment-emergent adverse events using meta-analytic techniques

The safety profiles of once-daily adjunctive levetiracetam (LEV) extended release (XR) (1000mg/day) and adjunctive LEV immediate release (IR) (500mg twice daily) were compared using data from three randomized, placebo (PBO)-controlled phase III clinical trials in patients with partial-onset seizures. MedDRA 9.0 treatment-emergent adverse events (TEAEs) were indirectly compared using meta-analytic techniques, including calculation of risk difference (RD) and mixed-effects analysis. Statistical significance was set at 10% alpha risk, the normative value for these analyses. Data from 555 patients older than 16 (204 LEV IR, 70 LEV XR, 281 PBO) were analyzed. Following adjustment for incidence of placebo TEAEs, LEV XR showed statistically significantly lower rates of TEAEs than LEV IR across nervous system disorders (RD=-18%, P=0.03), psychiatric disorders (RD=-11%, P=0.08), and metabolism and nutrition disorders (RD=-3%, P=0.08). Among nervous system disorders, the RD for headache favored LEV XR (RD=-11%, P=0.08). These results suggest that adjunctive LEV XR may be associated with a lower incidence of nervous system, psychiatric, and nutritional and metabolic TEAEs as compared with LEV IR. However, this difference was observed at a broad scale and not at a specific TEAE level except for headache.

May the best friend be an enemy if not recognized early: possible role of omega-3 against cardiovascular abnormalities due antipsychotics in the treatment of autism

Autism spectrum disorders (ASD) are neurodevelopment disorders that cause severe and pervasive impairment in socialization, communication, and behavior. Although the availability of antipsychotic treatment in ASD has expanded, we will be very careful with side effects of these pharmacological agents. Following this reasoning, emerging data indicate that some antipsychotics may be associated with cardiovascular adverse events (e.g., QT interval prolongation), suggesting that this could be correlated to sudden death. Quite interesting, substantial evidence from epidemiological and case-control studies indicates that omega-3 reduces the risk of cardiovascular mortality, particularly sudden cardiac death. In accordance to the above mentioned findings, as omega-3 fatty acids per se have a direct cardiovascular protective role, our paper hypothesized that omega-3 fatty acids supplementation in ASD patients treated with atypical antipsychotic drugs may reduce cardiac arrhythmias and hence sudden cardiac death.

Epilepsy and sudden unexpected death in epilepsy?: eat more fish! A group hypothesis

Epilepsy is the commonest serious neurological disorder and individuals with epilepsy are at higher risk of death than the general population and sudden unexpected death in epilepsy (SUDEP) is the most important direct epilepsy-related cause of death. Potential pathomechanisms for SUDEP are unknown, but it is very probable that cardiac arrhythmias during and between seizures play a potential role. The ultimate goal of SUDEP research is to develop methods to prevent it and nutritional aspects such as omega-3 fatty acid deficiency may have an interesting role in this scenario. Omega-3 fatty acids reduce the risk of cardiovascular mortality and are important for treating or preventing some neurological diseases, including epilepsy. A dietary modification or nutritional supplements increasing the ingestion of omega-3 fatty acids may help to ''save the brain'.

Duloxetine treatment for women with premenstrual dysphoric disorder: a single-blind trial

Premenstrual dysphoric disorder (PMDD) affects 3-8% of women of reproductive age and is characterized by severe mood symptoms that cause important functional impairment. Serotonergic antidepressants appear to be an effective treatment for this disorder. The purpose of this study was to collect evidence on the efficacy and tolerability of duloxetine, a dual reuptake inhibitor of serotonin and norepinephrine, in the treatment of PMDD. We conducted a pilot, single-blind, non-controlled, fixed-dose trial. After two cycles for diagnosis confirmation, including a single-blind placebo cycle, 20 women with PMDD were treated continuously for three menstrual cycles with 60 mg/d duloxetine. The primary measure of the efficacy of treatment with duloxetine was the significant reduction in premenstrual symptoms demonstrated by the comparison between the mean Daily Record of Severity of Problems (DRSP) scores at baseline to endpoint (p=0.0002). Statistically significant symptom reduction was observed in the first treatment cycle and throughout all the treatment phase. Clinical response, defined as a reduction 50% of baseline premenstrual symptoms, occurred in 65% of subjects (intention-to-treat population). Significant improvements were demonstrated by secondary measures, including reduction in self-rated functional impairment (p=0.01) and improvement in quality of life (p=0.04). The main side-effects associated with duloxetine were dry mouth, nausea, drowsiness, insomnia, decreased appetite, decreased libido, and sweating. Duloxetine was effective and generally well tolerated in the treatment of PMDD. Further large-scale, double-blind, placebo-controlled studies are needed to evaluate duloxetine as an additional treatment strategy for the management of PMDD.

Nicotine-induced memory impairment by increasing brain oxidative stress

Male Wistar rats were subjected to chronic nicotine treatment (0.3 mg/kg; 7 continuous days) and their memory performance was studied by means of Y-maze and multi-trial passive avoidance tasks. Nicotine significantly decreased spontaneous alternation in Y-maze task and step-through-latency in the multi-trial passive avoidance task, suggesting effects on both short-term memory and long-term memory, respectively. In addition, nicotine induced neuronal apoptosis, DNA fragmentation, reduced antioxidant enzymes activity, and increased production of lipid peroxidation and reactive oxygen species, suggesting pro-oxidant activity. Our results provide further support that nicotine-induced memory impairment is due to an increase in brain oxidative stress in rats.

History of depressive and/or anxiety disorders as a predictor of treatment response: a post hoc analysis of a 12-week, randomized, double-blind, placebo-controlled trial of paroxetine controlled release in patients with fibromyalgia

BACKGROUND

Despite of a high comorbidity of depressive and/or anxiety disorders with fibromyalgia, information on the clinical implications of this comorbidity is limited but antidepressants are commonly prescribed to treat fibromyalgia in clinical practice. We investigated whether a history of depressive and/or anxiety disorders was associated with response to paroxetine controlled release (CR) in the treatment of fibromyalgia.

METHODS

One hundred sixteen (116) fibromyalgia subjects were randomized to receive paroxetine CR or placebo for 12 weeks. The primary outcome was treatment response defined as >or=25% reduction in the Fibromyalgia Impact Questionnaire (FIQ) score. In multivariate logistic regression, we determined if a history of depression and/or anxiety disorders was an independent predictor of response to paroxetine CR.

RESULTS

In logistic regression, the history of depression and/or anxiety did not predict treatment response as measured by >or=25% reduction in Fibromyalgia Impact Questionnaire (FIQ) score (OR=0.66, 95% CI=.29-1.49, Wald=0.97, p=0.32), while the drug status (paroxetine CR) was significantly associated with treatment response (OR=2.57, CI=1.2-5.61, Wald=5.5, p=0.02).

CONCLUSION

A significant proportion of patients with fibromyalgia had a history of anxiety and or depressive disorders. However response to treatment of fibromyalgia symptoms with paroxetine CR was not associated with a history of depressive and/or anxiety disorders. Our findings need to be confirmed in more adequately-powered and well-designed subsequent studies.

Gustatory and olfactory function in patients with unipolar and bipolar depression

Although the crucial distinction between unipolar depressive disorder and bipolar disorder is the presence of mania (or hypomania) in the course of the latter, significant differences between unipolar and bipolar depression have also been found in clinical studies. The primary aim of the present investigation was to assess pleasantness/unpleasantness ratings of chemosensory stimuli in depressed patients, including subjects with unipolar and bipolar depression. Sensory aspects (thresholds and identification abilities) of gustatory and olfactory function were also assessed. There were no major differences between a depression group, as a whole, and healthy controls in terms of gustatory and olfactory thresholds and identification abilities. Similarly, pleasantness ratings of various gustatory and olfactory stimuli did not differ between the control and depression group. Gustatory and olfactory thresholds and identification abilities did not differ between individuals with unipolar and bipolar depression. Bipolar patients tended to rate less gustatory stimuli as unpleasant and more olfactory stimuli as pleasant compared to unipolar patients. The present results suggest that: i) depression is not associated with any major deficit in sensory aspects of gustatory and olfactory function or altered hedonic ratings of chemosensory stimuli; ii) hedonic responses to chemosensory stimuli tend to be increased in bipolar as compared to unipolar depressed patients.

Efficacy and safety of aripiprazole in the treatment of bipolar disorder: a systematic review

BACKGROUND

The current article is a systematic review concerning the efficacy and safety of aripiprazole in the treatment of bipolar disorder.

METHODS

A systematic Medline and repositories search concerning the usefulness of aripiprazole in bipolar disorder was performed, with the combination of the words 'aripiprazole' and 'bipolar'.

RESULTS

The search returned 184 articles and was last updated on 15 April 2009. An additional search included repositories of clinical trials and previous systematic reviews specifically in order to trace unpublished trials. There were seven placebo-controlled randomised controlled trials (RCTs), six with comparator studies and one with add-on studies. They assessed the usefulness of aripiprazole in acute mania, acute bipolar depression and during the maintenance phase in comparison to placebo, lithium or haloperidol.

CONCLUSION

Aripiprazole appears effective for the treatment and prophylaxis against mania. The data on bipolar depression are so far negative, however there is a need for further study at lower dosages. The most frequent adverse effects are extrapyramidal signs and symptoms, especially akathisia, without any significant weight gain, hyperprolactinaemia or laboratory test changes.

Insomnia in patients with depression: some pathophysiological and treatment considerations

The almost ubiquitous sleep disturbances in patients with depression commonly, but not always, subside with the remission of depression. Evidence linking insomnia with the risk of relapses in recurrent depression, as well as suicide, makes optimization of the treatment of insomnia associated with depression a priority. However, most antidepressant agents do not adequately address the sleep complaints in depression: their effects on sleep range from sizeable improvement to equally significant worsening. One approach to the management of insomnia associated with depression is to choose a sedating antidepressant agent such as trazodone, mirtazapine or agomelatine. A second approach is to start with a non-sedating antidepressant (e.g. the selective serotonin reuptake inhibitors, bupropion, venlafaxine or duloxetine); those with a persistent or treatment-emergent insomnia can be switched to a more sedating antidepressant, or offered a hypnotic or cognitive-behavioural therapy as adjunctive treatment. The review discusses the advantages and disadvantages of all treatment options, pharmacological and otherwise.

Ginkgo biloba: specificity of neuropsychological improvement--a selective review in search of differential effects

Extracts of Ginkgo biloba are widely used for the treatment of cognitive impairment. Whereas reviews have focused on the question whether ginkgo is effective to enhance cognition in general, little is known about specificity of improvement. This might be crucial for future trials, thus enabling hypotheses about sensitive outcome measures. Therefore, this article summarizes such information, i.e. neuropsychological effects of chronic administration of ginkgo in healthy and cognitively impaired subjects of any age. Objective psychometric test results were considered if they reflected distinct cognitive functions from randomized controlled group-studies (RCT). We reviewed 29 RCTs yielding 209 placebo-drug comparisons of psychometric scores in four different cognitive domains comprising 14 sub-functions. Whereas little specific information can be obtained from trials for treatment of dementia, a pattern of pharmacological actions on cognitive processes emerges here from studies for mild cognitive impairment (MCI), depression, multiple sclerosis and healthy young and elderly subjects. There is consistent evidence that chronic administration improves selective attention, some executive processes and long-term memory for verbal and non-verbal material. Further trials should be more comprehensive as there are few data available on some cognitive functions and psychometric flaws in the selection of tests and the interpretation of their results favouring predominantly beta-errors. Thus, though this pattern is encouraging it also asks for a cautious interpretation to date.

RETRACTED: Efficacy and safety of omega-3 for treatment of early-stage Peyronie's disease: A prospective, randomized, double-blind placebo-controlled study

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editor-in-Chief. Following the retraction of Dr. Safarinejad's work by other journals, The Journal of Sexual Medicine has undertaken an extensive re-review of all papers Dr. Safarinejad published with the journal. Following an intensive re-evaluation and close scrutiny of the manuscripts, our expert reviewers raised multiple concerning questions about the methodology, results, and statistical interpretation as presented in this article. Dr. Safarinejad was contacted to provide his original data and offer explanations to address the concerns expressed by the reviewers. Dr Safarinejad chose not to respond. Consequently, we can no longer verify the results or methods as presented and therefore retract the article.

Transitional polytherapy: tricks of the trade for monotherapy to monotherapy AED conversions

The goal of epilepsy therapy is to help patients achieve seizure freedom without adverse effects. While monotherapy is preferable in epilepsy treatment, many patients fail a first drug due to lack of efficacy or failure to tolerate an initial medication, necessitating an alteration in therapy. Sudden changes between monotherapies are rarely feasible and sometimes deleterious given potential hazards of acute seizure exacerbation or intolerable adverse effects. The preferred method for converting between monotherapies is transitional polytherapy, a process involving initiation of a new antiepileptic drug (AED) and adjusting it toward a target dose while maintaining or reducing the dose of the baseline medication. A fixed-dose titration strategy of maintaining the baseline drug dose while titrating the new medication is preferable when breakthrough seizures are occurring and no adverse effects are present. However, a flexible titration strategy involving reduction of the baseline drug dose to ensure adequate tolerability of the new adjunctive medication is preferred when patients are already experiencing adverse effects. This article reviews pharmacokinetic considerations pertinent for ensuring successful transitional polytherapy with the standard and newer antiepileptic drugs. Practical consensus recommendations "from an expect panel (SPECTRA, Study by a Panel of Experts Considerations for Therapy Replacement and Antiepileptics) for a successful monotherapy" AED conversions are then summarized. Transitional polytherapy is most successful when clinicians appropriately manage the titration strategy and consider pharmacokinetic factors germane to the baseline and new adjunctive medication.

Antioxidant therapy in multiple sclerosis

Reactive oxygen species (ROS) play an important role in various events underlying multiple sclerosis pathology. In the initial phase of lesion formation, ROS are known to mediate the transendothelial migration of monocytes and induce a dysfunction in the blood-brain barrier. Although the pathogenesis of MS is not completely understood, various studies suggest that reactive oxygen species contribute to the formation and persistence of multiple sclerosis lesions by acting on distinct pathological processes. The detrimental effects of ROS in the central nervous system are endowed with a protective mechanism consisting of enzymatic and non-enzymatic antioxidant. Antioxidant therapy may therefore represent an attractive treatment of MS. Several studies have shown that antioxidant therapy is beneficial in vitro and in vivo in animal models for MS. Since oxidative damage has been known to be involved in inflammatory and autoimmune-mediated tissue destruction in which, modulation of oxygen free radical production represents a new approach to the treatment of inflammatory and autoimmune diseases. Several experimental studies have been performed to see whether dietary intake of several antioxidants can prevent and or reduce the progression of EAE or not. Although a few antioxidants showed some efficacy in these studies, little information is available on the effect of treatments with such compounds in patients with MS. In this review, our aim is to clarify the therapeutic efficacy of antioxidants in MS disease.

Adverse event load in bipolar participants receiving either carbamazepine immediate-release or extended-release capsules: a blinded, randomized study

In epilepsy, slow-release formulations of carbamazepine (CBZ) have fewer adverse events (AEs) compared with immediate-release (IR) formulations. As CBZ is used for mania, it is important to determine whether a similar pattern exists for bipolar patients. This was a 3-month, blinded, random-assignment study to an IR formulation or extended-release carbamazepine capsules (ERCC, Equetro) in type I or type II bipolar patients already on CBZ or clinically determined to benefit from it. Dosages were titrated to patients' clinical needs. Mood and AE ratings were performed at baseline and monthly for 3 months. There was no difference in mood ratings or in the total level of AEs in patients receiving IR or ERCC. However, autonomic AEs (5.0+/-1.1 vs. 2.0+/-0.7, P = 0.02) and gastrointestinal AEs (1.6+/-0.4 vs. 0.6+/-0.3, P = 0.05) were significantly less in participants receiving ERCC. CBZ level in patients receiving ERCC were higher (9.2+/-1.7 vs. IR 7.2+/-1.3 microg/ml, P = 0.005). Total AE load was directly related to CBZ level only in participants receiving the IR formulation. In conclusion, ERCC is better tolerated than IR CBZ in bipolar patients.

A prospective pilot study of levetiracetam for body dysmorphic disorder

INTRODUCTION

Body dysmorphic disorder (BDD) is an often severe disorder, but few treatment studies have been conducted.

OBJECTIVE

This pilot study explored the efficacy and safety of the antiepileptic medication levetiracetam for BDD.

METHODS

Seventeen subjects with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition BDD participated in a 12-week open-label levetiracetam trial. Subjects were assessed at regular intervals with standard measures.

RESULTS

In intent-to-treat analyses, scores on the Yale-Brown Obsessive Compulsive Scale Modified for BDD (BDD-YBOCS), the primary outcome measure, decreased from 32.5+/-4.7 at baseline to 21.5+/-11.0 at endpoint (P<.001). Approximately 60% (n=9) of subjects were responders (>30% decrease on the BDD-YBOCS). The mean time to response was 4.6+/-2.8 (range: 2-10) weeks. Scores also significantly improved on the Brown Assessment of Beliefs Scale, the Hamilton Rating Scale for Depression, the Global Assessment of Functioning Scale, and the Social and Occupational Functioning Assessment Scale. Scores did not significantly improve on the Quality of Life Enjoyment and Satisfaction Questionnaire, the Beck Anxiety Inventory, or the Social Phobia Inventory. The mean endpoint dose of levetiracetam was 2,044.1+/-1,065.2 (range: 250-3,000) mg/day, and it was relatively well-tolerated.

CONCLUSION

Randomized, double-blind placebo-controlled studies of levetiracetam for BDD are needed to confirm these preliminary findings.

Insights into liaison between antiepileptic drugs and bone

The adverse effect on bone caused by chronic anticonvulsant therapy causes multiple abnormalities in calcium and bone metabolism, varying from bone turnover, without significant loss of cortical or trabecular bone, to osteopenia/osteoporosis and to osteomalacic disorder. The studies conducted to date have documented anticonvulsant bone disease as a state of increased bone remodeling. With the newer antiepileptic drugs (AEDs) gaining importance and starting to replace conventional medicines, it may be appropriate to compare them with the conventional AEDs and to examine their impact on multiple aspects of bone health. This review focuses on the status of the bony effects of AEDs.

Have last-observation-carried-forward analyses caused us to favour more toxic dementia therapies over less toxic alternatives? A systematic review

BACKGROUND

Intention-to-treat analysis is used in the analysis of randomized controlled trials to preserve trial power in the presence of missing subject data as well as to control for both known and unknown confounding factors. One form of intention-to-treat analysis is last-observation-carried-forward (LOCF). Concerns exist regarding whether it is appropriate to use LOCF in analyses involving progressive conditions or in situations where missing data are non-random (e.g., subjects drop out because of treatment side effects or differing disease severity).

OBJECTIVE

To examine the use of intention-to-treat imputation of missing data techniques, and specifically LOCF, in randomized controlled trials of the use of cholinesterase inhibitors and memantine to treat Alzheimer's disease, vascular dementia, mixed dementia and mild cognitive impairment.

METHODS

We conducted a systematic electronic search of MEDLINE and the Cochrane Central Register of Controlled Trials from 1984 to 2008 for double-blinded, randomized controlled trials of cholinesterase inhibitors or memantine that examined progressive symptoms in Alzheimer's disease, vascular dementia, mixed dementia and mild cognitive impairment. We collected data on the use of intention-to-treat and non-intention-to-treat analyses and on contraindications to the use of LOCF analysis and we performed quality assessments of included trials.

RESULTS

Of the 57 studies that met the inclusion criteria, 12 did not report intention-to-treat analyses. Of the 34 studies that employed LOCF as the only form of intention-to-treat analysis, 24 reported conditions that could produce biased LOCF analyses favouring the drug under study. The latter finding was more common in cholinesterase inhibitor trials than in memantine studies.

CONCLUSIONS

The published results of some randomized controlled trials of dementia drugs may be inaccurate (i.e., drug effectiveness may be exaggerated) or invalid (i.e., there may be false-positive results) because of bias introduced through the inappropriate use of LOCF analyses. This bias favours cholinesterase inhibitors, potentially preventing funding of and patient access to less toxic treatment options such as memantine. Licensing agencies should consider whether to accept LOCF analyses in research on dementias and other chronic progressive conditions.

Cognitive and behavioral changes related to symptom improvement among patients with a mood disorder receiving intensive cognitive-behavioral therapy

OBJECTIVE

To examine the relationship between cognitive and behavioral changes associated with cognitive-behavioral therapy (CBT) and treatment response in an intensive partial hospital (PH) setting.

METHODS

Study participants were 105 patients with mood disorders receiving treatment in a private psychiatric PH setting. The flexible treatment model used evidence-based CBT interventions adapted to the PH context, with emphases on psychoeducation and skills training. Participants completed self-report measures at admission and discharge to assess psychological distress, depression, negative automatic thoughts, and behavioral activation. Mean treatment duration was 9 days.

RESULTS

Decreased negative automatic thoughts and increased behavioral activation predicted reduction of depressive symptoms; however, only decreased negative automatic thoughts was predictive of patients' overall level of psychological distress.

CONCLUSIONS

These results suggest that a CBT intervention adapted for use in a PH setting can be an effective treatment for severe mood disorders. Furthermore, although the design used in this study precludes causal inferences, depressive symptom improvement appears to be associated with decreased negative automatic thoughts and increased behavioral activation. Implications for the delivery of CBT in PH programs and future directions for research are discussed.

Modulation of in vivo oxidative status by exogenous corticosterone and restraint stress in rats

Physical and psychological stressors not only enhance activity of the hypothalamo-pituitary-adrenocortical axis, but also cause oxidative damage by inducing an imbalance between the in vivo pro-oxidant and antioxidant status. The involvement of adrenal steroid stress hormones in oxidative damage associated with these stressors has not been extensively investigated. Therefore, this study was designed to probe any direct role of glucocorticoids on induction of oxidative processes by comparing the effects of low, intermediate and high doses of exogenously administered corticosterone, without other applied stressors, on a wide range of key components of the antioxidant defence system. The data presented here indicate a substantial decline in antioxidant defences by actions of corticosterone, evidenced by coordinate decreases in the activities in the brain, liver and heart of free-radical scavenging enzymes superoxide dismutase (SOD), catalase (CAT), glutathione S-transferase (GST) and glutathione reductase (GR), as well as the non-enzymatic antioxidants glutathione (GSH) and serum urate. Also, lipid peroxidation and protein carbonyl contents, oxidative stress markers, were found to be significantly increased in brain, liver and heart. The compromised in vivo antioxidant status was strikingly analogous to the deleterious effects of restraint stress, indicating a direct effect of stress hormones on induction of oxidative damage during physical or psychological stress. A dose-dependent decrease of SOD and CAT, and increase in protein oxidation was observed between the high (40 mg/kg) and low (10 mg/kg) doses of corticosterone. The findings have fundamental implications for oxidative stress as a major pathological mechanism in the maladaptation to chronic stress. Thus, the study suggests that stress hormones have a causal role in impacting oxidative processes induced during the adaptive response. This may hold important implications for pharmacological interventions targeting cellular antioxidants as a promising strategy for protecting against oxidative insults in various psychiatric and non-psychiatric conditions induced by physical or psychological stress.

Amyloid beta-protein assembly as a therapeutic target of Alzheimer's disease

Alzheimer's disease (AD), the most common neurodegenerative disorder in the aged, is characterized by the cerebral deposition of fibrils formed by the amyloid beta-protein (Abeta), a 40-42 amino acid peptide. The folding of Abeta into neurotoxic oligomeric, protofibrillar, and fibrillar assemblies is hypothesized to be the key pathologic event in AD. Abeta is formed through cleavage of the Abeta precursor protein by two endoproteinases, beta-secretase and gamma-secretase, that cleave the Abeta N-terminus and C-terminus, respectively. These facts support the relevance of therapeutic strategies targeting Abeta production, assembly, clearance, and neurotoxicity. Currently, no disease-modifying therapeutic agents are available for AD patients. Instead, existing therapeutics provide only modest symptomatic benefits for a limited time. We summarize here recent efforts to produce therapeutic drugs targeting Abeta assembly. A number of approaches are being used in these efforts, including immunological, nutraceutical, and more classical medicinal chemical (peptidic inhibitors, carbohydrate-containing compounds, polyamines, "drug-like" compounds, chaperones, metal chelators, and osmolytes), and many of these have progressed to phase III clinical trails. We also discuss briefly a number of less mature, but intriguing, strategies that have therapeutic potential. Although initial trials of some disease-modifying agents have failed, we argue that substantial cause for optimism exists.

Oxidative stress and cognitive ability in adults with Down syndrome

AIMS

We aimed to study the hypothesis that high levels of superoxide dismutase (SOD1), previously reported in Down syndrome, would be associated with poorer ability on cognitive tests. Compensatory rises in the activity of glutathione peroxidase (GPx) was expected to be associated with better ability, so that a high ratio between SOD1 and GPx was hypothesised to be the best predictor of poorer cognitive performance.

METHODS

32 adults with Down syndrome between the ages of 18 and 45 years donated blood samples for SOD1 and GPx assays and urine for Isoprostane 8,12-iso-iPF(2alpha)-VI assay, a specific biomarker of lipid peroxidation in vivo. Informants rated functional ability and memory function for all participants, and those adults with DS that was able to, also completed psychometric assessments of language ability and memory.

RESULTS

Neither SOD1 nor GPx were related to the elevated markers of lipid peroxidation previously described in living adults with DS, and our hypothesis that an increased SOD1/GPx ratio would be correlated with worse performance on cognitive or functional measures was not supported. Contrary to our hypothesis, we found that low SOD1/GPx ratios were associated with worse memory ability, which remained after controlling for confounders such as sex, age or nutritional supplements.

CONCLUSIONS

The anti-oxidant system in DS is implicated in the cognitive phenotype associated with the chromosomal disorder, but the variations in the phenotype could result from several possible gene or gene product interactions. Much further research is required before it will be possible to counteract the oxidative stress associated with DS.

Protection against beta-amyloid induced abnormal synaptic function and cell death by Ginkgolide J

A new Ginkgo biloba extract P8A (TTL), 70% enriched with terpene trilactones, prevents A beta(1-42) induced inhibition of long-term potentiation in the CA1 region of mouse hippocampal slices. This neuroprotective effect is attributed in large part to ginkgolide J that completely replicates the effect of the extract. Ginkgolide J is also capable of inhibiting cell death of rodent hippocampal neurons caused by A beta(1-42). This beneficial and multi-faceted mode of action of the ginkgolide makes it a new and promising lead in designing therapies against Alzheimer's disease.

Ginkgo biloba for cognitive impairment and dementia

BACKGROUND

Extracts of the leaves of the maidenhair tree, Ginkgo biloba, have long been used in China as a traditional medicine for various disorders of health. A standardized extract is widely prescribed for the treatment of a range of conditions including memory and concentration problems, confusion, depression, anxiety, dizziness, tinnitus and headache. The mechanisms of action are thought to reflect the action of several components of the extract and include increasing blood supply by dilating blood vessels, reducing blood viscosity, modification of neurotransmitter systems, and reducing the density of oxygen free radicals.

OBJECTIVES

To assess the efficacy and safety of Ginkgo biloba for dementia or cognitive decline.

SEARCH STRATEGY

The Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched on 20 September 2007 using the terms: ginkgo*, tanakan, EGB-761, EGB761, "EGB 761" and gingko*. The CDCIG Specialized Register contains records from all major health care databases (The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many trials databases and grey literature sources.

SELECTION CRITERIA

Randomized, double-blind studies, in which extracts of Ginkgo biloba at any strength and over any period were compared with placebo for their effects on people with acquired cognitive impairment, including dementia, of any degree of severity.

DATA COLLECTION AND ANALYSIS

Data were extracted from the published reports of the included studies, pooled where appropriate and the treatment effects or the risks and benefits estimated.

MAIN RESULTS

36 trials were included but most were small and of duration less than three months. Nine trials were of six months duration (2016 patients). These longer trials were the more recent trials and generally were of adequate size, and conducted to a reasonable standard. Most trials tested the same standardised preparation of Ginkgo biloba, EGb 761, at different doses, which are classified as high or low. The results from the more recent trials showed inconsistent results for cognition, activities of daily living, mood, depression and carer burden. Of the four most recent trials to report results three found no difference between Ginkgo biloba and placebo, and one found very large treatment effects in favour of Ginkgo biloba.There are no significant differences between Ginkgo biloba and placebo in the proportion of participants experiencing adverse events.A subgroup analysis including only patients diagnosed with Alzheimer's disease (925 patients from nine trials) also showed no consistent pattern of any benefit associated with Ginkgo biloba.

AUTHORS' CONCLUSIONS

Ginkgo biloba appears to be safe in use with no excess side effects compared with placebo. Many of the early trials used unsatisfactory methods, were small, and publication bias cannot be excluded. The evidence that Ginkgo biloba has predictable and clinically significant benefit for people with dementia or cognitive impairment is inconsistent and unreliable.

Intra-amygdaloid infusion of Ginkgo biloba leaf extract (EGb761) facilitates fear-potentiated startle in rats

RATIONALE

Ginkgo biloba extract, EGb761, is one of the most commonly used herbal supplements throughout Western society. It has been used in the treatment of various common geriatric complaints including short-term memory loss. We showed that acute systemic administration of EGb761 enhanced fear-potentiated startle (FPS) in rats. Little is known about the behavioral effects of centrally administered EGb761 on FPS.

OBJECTIVE

The current study was performed to evaluate the involvement of basolateral nucleus of amygdala (BLA) in the EGb761 facilitation effect on FPS.

METHODS AND RESULT

Male adult SD rats were used. EGb761 was infused into cerebroventricle or basolateral nucleus of amygdala 10 min prior to fear conditioning. Animals were then tested for FPS 24 h later. Results showed that (1) intra-cerebroventricular infusion of EGb761 (0.1, 1.0, or 3.0 microg/3.0 microl per side, bilaterally) and intra-amygdaloid infusion of EGb761 (1.0, 14.0, or 28.0 ng/microl per side, bilaterally) 30 and 10 min prior to fear conditioning, respectively, facilitated FPS in a dose-dependent manner. (2) Administration of EGb761 did not impair an animal's basal startle response or pain perception. (3) Subsequent control experiment's results indicated that the facilitation effect of EGb761 on the acquisition was not due to anxiogenic effect or non-specific effect.

CONCLUSIONS

These results suggested that a single dose of EGb761 also has memory-enhancing effects in young animals. In addition, BLA is the central locus for EGb761 facilitation effect on FPS.

Effect of fish oils containing different amounts of EPA, DHA, and antioxidants on plasma and brain fatty acids and brain nitric oxide synthase activity in rats

BACKGROUND

The interest in n-3 polyunsaturated fatty acids (PUFAs) has expanded significantly in the last few years, due to their many positive effects described. Consequently, the interest in fish oil supplementation has also increased, and many different types of fish oil supplements can be found on the market. Also, it is well known that these types of fatty acids are very easily oxidized, and that stability among supplements varies greatly.

AIMS OF THE STUDY

In this pilot study we investigated the effects of two different types of natural fish oils containing different amounts of the n-3 PUFAs eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and antioxidants on plasma and brain fatty acids, blood lipids, vitamin E, and in vivo lipid peroxidation, as well as brain nitric oxide synthase (NOS) activity, an enzyme which has been shown to be important for memory and learning ability.

METHODS

Sprague-Dawley rats were divided into four groups and fed regular rat chow pellets enriched with 5% (w/w) of butter (control group), a natural fish oil (17.4% EPA and 11.7% DHA, referred to as EPA-rich), and a natural fish oil rich in DHA (7.7% EPA and 28.0% DHA, referred to as DHA-rich). Both of the fish oils were stabilized by a commercial antioxidant protection system (Pufanox) at production. The fourth group received the same DHA-rich oil, but without Pufanox stabilization (referred to as unstable). As an index of stability of the oils, their peroxide values were repeatedly measured during 9 weeks. The dietary treatments continued until sacrifice, after 10 days.

RESULTS

Stability of the oils varied greatly. It took the two stabilized oils 9 weeks to reach the same peroxide value as the unstable oil reached after only a few days. Both the stabilized EPA- and DHA-rich diets lowered the triacylglycerols and total cholesterol compared to control (-45%, P < 0.05 and -54%, P < 0.001; -31%, P < 0.05 and -25%, P < 0.01) and so did the unstable oil, but less efficiently. Only the unstable oil increased in vivo lipid peroxidation significantly compared to control (+40%, P < 0.001). Most of the fatty acids in the plasma phospholipids were significantly affected by both the EPA- and DHA-rich diets compared to control, reflecting their specific fatty acid pattern. The unstable oil diet resulted in smaller changes, especially in n-3 PUFAs. In the brain phospholipids the changes were less pronounced, and only the diet enriched with the stabilized DHA-rich oil resulted in a significantly greater incorporation of DHA (+13%, P < 0.01), as well as total n-3 PUFAs (+13%, P < 0.01) compared to control. Only the stabilized DHA-rich oil increased the brain NOS activity (+33%, P < 0.01).

CONCLUSIONS

Both the EPA- and DHA-rich diets affected the blood lipids in a similarly positive manner, and they both had a large impact on plasma phospholipid fatty acids. It was only the unstable oil that increased in vivo lipid peroxidation. However, the intake of DHA was more important than that of EPA for brain phospholipid DHA enrichment and brain NOS activity, and the stability of the fish oil was also important for these effects.

Treatment Target Test Dementia (3TD)

OBJECTIVE

So far goal-oriented therapy in dementia cannot be measured sufficiently. There are no tests that detect a profile of capacities that could describe the targets of training. Thus, it was aimed to develop a test that uncovers a profile of capacities in patients suffering from dementia.

METHODS

Three groups of subjects (n = 156), 30 patients suffering from dementia of the Alzheimer type, 28 from depressive disorder and 98 healthy age-comparable controls were included in the study. Building on already existing tests, items were developed to cover intelligence, visuo-spatial abilities, cognitive and social problem solving, emotional and executive abilities. All subjects were investigated with the Training Target Test Dementia (3TD). To calculate convergence validity, the Test for the Early Detection of Dementia from depression (TE4D) and the Beck Depression Inventory were assessed. Descriptively, profiles were calculated. Group differences were studied with the Kruskal-Wallis and the Mann-Whitney-U-test.

RESULTS

Characteristic neuropsychological capacity profiles were found within the three groups. Differences between the groups were significant for all subtests. Significantly, the 3TD separated patients with dementia from controls. It reached high sensitivity and acceptable specificity. The convergence validity to the TE4D was significant (r = 0.77).

CONCLUSIONS

The capacity profiles detected may allow for specified therapeutic modules to be scheduled. Moreover, the 3TD will be suitable to discriminate between patients suffering from dementia, depression as well as healthy age-comparable controls. For therapeutic improvement, further investigation will be needed to prove its sensitivity.

Why do so many drugs for Alzheimer's disease fail in development? Time for new methods and new practices?

Alzheimer's disease (AD) drug developments and clinical trials (CT) remain vulnerable to problems that undermine research validity. Investigations of CT methods reveal how numerous factors decrease active drug-placebo group differences and increase variance, thereby reducing power to reach statistical significance for outcome measure differences in AD CTs. Such factors include, amongst many, inaccuracy, imprecision, bias, failures to follow or lack of operational protocols for applying CT methods, inter-site variance, and lack of homogeneous sampling using disorder criteria. After a review of the literature and survey of a sample of AD and Mild Cognitive Impairment (MCI) CTs, the authors question whether problems of human error preclude AD researchers from continuing their dependence on rated outcome measures for CTs. The authors propose that the realities of AD, especially a probable irreversible progression of neuropathology prior to onset of clinical symptoms or signs capable of differentiating persons at risk for AD from normal aged, require AD investigators and clinicians to privilege biomarkers and encourage their development as surrogate targets for preventive AD treatment developments, testing, and use in clinical practice.

Emerging amyloid beta (Ab) peptide modulators for the treatment of Alzheimer's disease (AD)

BACKGROUND

According to the 'amyloid cascade hypothesis' of Alzheimer's disease (AD), abnormal processing of beta-amyloid precursor protein (betaAPP) into toxic amyloid beta (Abeta)-peptides is central to the etiopathology of this uniquely human brain disorder.

OBJECTIVE

To review current AD drugs, pharmacological approaches and strategies aimed at modulating Abeta-peptide generation and/or aggregation in the treatment of AD.

METHODS

Data searches at various websites: Alzheimer Research Forum; individual drug company databases; Medline; Pharmaprojects database; unpublished research; inter-University research communications.

RESULTS/CONCLUSION

Considerable research effort has focused on secretase-mediated mechanisms of betaAPP processing, and the latest pharmacological strategies have used selective Abeta-peptide-lowering agents (SALA) to provide therapeutic benefit against Abeta-initiated neurodegenerative pathology. Currently, dedicated anticholinesterase, glutamatergic agonist and Abeta-peptide immunization have had little impact in the clinical treatment of AD. One unexpected benefit of statins (HMG-CoA inhibitors), besides their cholesterol lowering abilities, has been their ancillary effects in potentiating the enzymatic mechanisms that generate Abeta-peptides. The long-term benefits or complications of statin-based therapies for use in the clinical management of AD are not known.

The other side of the coin: Beneficiary effect of omega-3 fatty acids in sudden unexpected death in epilepsy

The epilepsies are the most common serious neurological condition. People with epilepsy have a two- to threefold increased risk of dying prematurely than those without epilepsy, and the most common epilepsy-related category of death is sudden unexpected death in epilepsy (SUDEP). The exact pathophysiological causes of SUDEP remain unknown, but it is very probable that cardiac arrhythmia during and between seizures plays a potential role. Although the pharmacological treatments available for the epilepsies have expanded, antiepileptic drugs are still limited in clinical efficacy. In this regard, several factors such as genetic, environmental, and social can contribute to the inefficacy of therapeutic outcome in patients with epilepsy. Among these factors, nutritional aspects, that is, omega-3 fatty acid deficiency, have an interesting role in this scenario. Animal and clinical studies have demonstrated that omega-3 fatty acids may be useful in the prevention and treatment of epilepsy. Moreover, as omega-3 fatty acids per se have been shown to reduce cardiac arrhythmias and sudden cardiac deaths, it has been proposed that omega-3 fatty acid supplementation in patients with refractory seizures may reduce seizures and seizure-associated cardiac arrhythmias and, hence, SUDEP. Given their relative safety and general health benefits, our update article summarizes the knowledge of the role of dietary omega-3 fatty acids in epilepsy.

The effects of omega-3 fatty acids monotherapy in Alzheimer's disease and mild cognitive impairment: a preliminary randomized double-blind placebo-controlled study

A 24-week, randomized, double-blind placebo-controlled study was carried out to test the feasibility of using omega-3 polyunsaturated fatty acids (PUFAs) monotherapy in people with cognitive impairment and to explore its effects on cognitive function and general clinical condition in these participants. Twenty three participants with mild or moderate Alzheimer's disease and twenty three with mild cognitive impairment were randomized to receive omega-3 PUFAs 1.8 g/day or placebo (olive oil). The data of 35 (76%) participants with at least one post-treatment visit was analyzed. There were no severe adverse effects in either group and it suggests that omega-3 PUFAs were well tolerable in this population. The treatment group showed better improvement on the Clinician's Interview-Based Impression of Change Scale (CIBIC-plus) than those in the placebo group over the 24 week follow-up (p=0.008). There was no significant difference in the cognitive portion of the Alzheimer's Disease Assessment Scale (ADAS-cog) change during follow-up in these two groups. However, the omega-3 fatty acids group showed significant improvement in ADAS-cog compared to the placebo group in participants with mild cognitive impairment (p=0.03), which was not observed in those with Alzheimer's disease. Higher proportions of eicosapentaenoic acid on RBC membranes were also associated with better cognitive outcome (p=0.003). Further studies should be considered with a larger-sample size, diet registration, higher dosages, comparisons between different combinations of PUFAs, and greater homogeneity of participants, especially those with mild Alzheimer's disease and mild cognitive impairment.

New developments for the pharmacological treatment of alcohol withdrawal syndrome. A focus on non-benzodiazepine GABAergic medications

Alcohol withdrawal syndrome (AWS) can be a life-threatening condition affecting some alcohol-dependent patients who abruptly discontinue or decrease their alcohol consumption. The main objectives of the clinical management of AWS include: to decrease the severity of symptoms, prevent more severe withdrawal clinical manifestations and facilitate entry of the patient into a treatment program in order to attempt to achieve and maintain long-term abstinence from alcohol. At present, benzodiazepines represent the drugs of choice in the treatment of AWS. However, in line with the possible side effects and addictive properties related to benzodiazepine use, there is growing evidence to suggest that non-benzodiazepine GABAergic compounds represent promising medications in the treatment of alcohol-dependent patients. This review focuses on research into non-benzodiazepine GABAergic medications for the treatment of AWS. Among them, carbamazepine, gabapentin and valproic acid are the most studied. The studies on carbamazepine seem to be the most compelling. Preliminary data have also suggested the possible utility of baclofen and topiramate, although further evidence is needed. The promising results in terms of both safety and efficacy are reported. However, we also note the need of more methodologically controlled studies on a greater number of patients, involving more complicated forms of AWS.

Crosstalk between calcium and redox signaling: from molecular mechanisms to health implications

Studies done many years ago established unequivocally the key role of calcium as a universal second messenger. In contrast, the second messenger roles of reactive oxygen and nitrogen species have emerged only recently. Therefore, their contributions to physiological cell signaling pathways have not yet become universally accepted, and many biological researchers still regard them only as cellular noxious agents. Furthermore, it is becoming increasingly apparent that there are significant interactions between calcium and redox species, and that these interactions modify a variety of proteins that participate in signaling transduction pathways and in other fundamental cellular functions that determine cell life or death. This review article addresses first the central aspects of calcium and redox signaling pathways in animal cells, and continues with the molecular mechanisms that underlie crosstalk between calcium and redox signals under a number of physiological or pathological conditions. To conclude, the review focuses on conditions that, by promoting cellular oxidative stress, lead to the generation of abnormal calcium signals, and how this calcium imbalance may cause a variety of human diseases including, in particular, degenerative diseases of the central nervous system and cardiac pathologies.

Enhancement of sleep stability with Tai Chi exercise in chronic heart failure: preliminary findings using an ECG-based spectrogram method

OBJECTIVE

To assess the effects of a 12-week Tai Chi exercise program on sleep using the sleep spectrogram, a method based on a single channel electrocardiogram (ECG)-derived estimation of cardiopulmonary coupling, previously shown to identify stable and unstable sleep states.

METHODS

We retrospectively analyzed 24-h continuous ECG data obtained in a clinical trial of Tai Chi exercise in patients with heart failure. Eighteen patients with chronic stable heart failure, left ventricular ejection fraction

RESULTS

At 12 weeks, those who participated in Tai Chi showed a significant increase in HFC (+0.05+/-0.10 vs. -0.06+/-0.09 % ETST, p=0.04) and significant reduction in LFC (-0.09+/-0.09 vs. +0.13+/-0.13 % ETST, p<0.01), compared to patients in the control group. Correlations were seen between improved sleep stability and better disease-specific quality of life.

CONCLUSIONS

Tai Chi exercise may enhance sleep stability in patients with chronic heart failure. This sleep effect may have a beneficial impact on blood pressure, arrhythmogenesis and quality of life.

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Key Words

• exercise
• heart failure
• heart rate variability
• mind-body
• sleep stability

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MESH Headings

• Adult
• Aged
• Chronic Disease
• Combined Modality Therapy
• Electrocardiography, Ambulatory
• Exercise Test
• Female
• Fourier Analysis
• Heart Failure/psychology
• Heart Failure/rehabilitation
• Heart Rate
• Humans
• Male
• Middle Aged
• Polysomnography
• Quality of Life/psychology
• Signal Processing, Computer-Assisted
• Sleep Deprivation/psychology
• Sleep Deprivation/rehabilitation
• Sleep Initiation and Maintenance Disorders/psychology
• Sleep Initiation and Maintenance Disorders/rehabilitation
• Tai Ji

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Grants

• P41-RR13622 NCRR NIH HHS
• T32 AT000051 NCCIH NIH HHS
• K24 AT00589 NCCIH NIH HHS
• P41 RR013622 NCRR NIH HHS
• P60 AG008812 NIA NIH HHS
• T32 AT00051 NCCIH NIH HHS
• P30 AG028717 NIA NIH HHS
• K23 AT002624 NCCIH NIH HHS
• P60-AG08812 NIA NIH HHS
• K24 AT000589 NCCIH NIH HHS
• T32 AG023480 NIA NIH HHS

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Affiliation(s)

Gloria Y Yeh Division for Research and Education in Complementary and Integrative Medical Therapies, Harvard Medical School, Boston, MA 02215, USA.
Joseph E Mietus
Chung-Kang Peng
Russell S Phillips
Roger B Davis
Peter M Wayne
Ary L Goldberger
Robert J Thomas

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Collaborators Collapse

Oxcarbazepine for the treatment of binge eating disorder: a case series

We present a case series of nine obese outpatients with a diagnosis of binge eating disorder who were treated with a flexible dose of the anticonvulsant oxcarbazepine. The drug has not previously been used to treat this disorder. Five patients dropped out at various points of the study, giving only fragmented data. Where data were available, all patients reported side effects (n=7) and some showed a reduction (n=4) or no change (n=3) in binge episode frequency. Some patients lost weight over the study period (n=3; range, 3-5 kg); others showed no change (n=2) or an increase in weight (n=3; range, 1.8-2.9 kg). Our results were inconsistent, but the drug was effective for some patients who showed marked impulsivity in eating behaviours and depressive symptoms.

Treatment options in Alzheimer's disease: maximizing benefit, managing expectations

Alzheimer's disease (AD) is becoming an increasingly heavy burden on the society of developed countries, and physicians now face the challenge of providing efficient treatment regimens to an ever-higher number of individuals affected by the disease. Currently approved anti-AD therapies - the cholinesterase inhibitors and the N-methyl-D-aspartate receptor antagonist memantine - offer modest symptomatic relief, which can be enhanced using combination therapy with both classes of drugs. Additionally, alternative therapies such as nonsteroidal anti-inflammatory drugs, vitamin E, selegiline, Ginkgo biloba extracts, estrogens, and statins, as well as behavioral and lifestyle changes, have been explored as therapeutic options. Until a therapy is developed that can prevent or reverse the disease, the optimal goal for effective AD management is to develop a treatment regimen that will yield maximum benefits for individual patients across multiple domains, including cognition, daily functioning, and behavior, and to provide realistic expectations for patients and caregivers throughout the course of the disease. This review provides a basic overview of approved AD therapies, discusses some pharmacologic and nonpharmacologic treatment strategies that are currently being investigated, and offers suggestions for optimizing treatment to fit the needs of individual patients.

Preventing tomorrow's sudden cardiac death in epilepsy today: what should physicians know about this?

Approximately 1% of the population has epilepsy, the most common neurological disorder. Moreover, people with epilepsy are more likely to die prematurely than those without epilepsy, and the most common epilepsy-related category of death is sudden unexpected death in epilepsy (SUDEP). Information concerning risk factors for SUDEP is conflicting, but potential risk factors include: age, early onset of epilepsy, duration of epilepsy, uncontrolled seizures, seizure frequency, number of antiepileptic drugs and winter temperatures. Additionally, the cause of SUDEP is still unknown; however, the most commonly suggested mechanisms are cardiac abnormalities during and between seizures. This review discusses the epidemiology, risk factors, etiology, and preventative measures in the management of SUDEP.

Management Strategies for Premenstrual Syndrome/Premenstrual Dysphoric Disorder

Objective:

To evaluate the current nonpharmacologic and pharmacologic treatment options for symptoms of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD).

Data Sources:

Literature was obtained through searches of MEDLINE Ovid (1950–March week 3, 2008) and EMBASE Drugs and Pharmacology (all years), as well as a bibliographic review of articles identified by the searches. Key terms included premenstrual syndrome, premenstrual dysphoric disorder, PMS, PMDD, and treatment.

Study Selection/Data Extraction:

All pertinent clinical trials, retrospective studies, and case reports in human subjects published in the English language were identified and evaluated for the safety and efficacy of pharmacologic and nonpharmacologic treatments of PMS/PMDD. Data from these studies and information from review articles were included in this review.

Data Synthesis:

Selective serotonin-reuptake inhibitors (SSRIs) have been proven safe and effective for the treatment of PMDD and are recommended as first-line agents when pharmacotherapy is warranted. Currently fluoxetine, controlled-release paroxetine, and sertraline are the only Food and Drug Administration-approved agents (or this indication. Suppression of ovulation using hormonal therapies is an alternative approach to treating PMDD when SSRIs or second-line psychotropic agents are ineffective; however, adverse effects limit their use. Anxiolytics, spironolactone, and nonsteroidal antiinflammatory drugs can be used as supportive care to relieve symptoms. Despite lack of specific evidence, lifestyle modifications and exercise are first-line recommendations for all women with PMS/PMDD and may be all that is needed to treat mild-to-moderate symptoms. Herbal and vitamin supplementation and complementary and alternative medicine have been evaluated for use in PMS/PMDD and have produced unclear or conflicting results. More controlled clinical trials are needed to determine their safety and efficacy and potential for drug interactions.

Conclusions:

Healthcare providers need to be aware of the symptoms of PMS and PMDD and the treatment options available. Treatment selection should be based on Individual patient symptoms, concomitant medical history, and need for contraception.

Direct enhancement of hippocampal dopamine or serotonin levels as a pharmacodynamic measure of combined antidepressant-anticonvulsant action

The neurobiological relationships between epilepsy and depression are receiving increased experimental attention. A key role for limbic monoamines in depression has been established and we recently showed the importance of hippocampal monoamines in limbic seizure control. We here studied whether anticonvulsant compounds are antidepressant and can elevate hippocampal dopamine (DA) or serotonin (5-HT) levels determined by in vivo microdialysis in rats. We used assessment of seizure severity in the focal pilocarpine model, antidepressant-like activity within the rat forced swim and the mouse tail suspension tests, and locomotor activity in an open field as behavioural tests. We studied the tricyclic antidepressant imipramine, the selective 5-HT reuptake inhibitor citalopram and the selective DA reuptake blocker GBR-12909. These compounds with combined antidepressant-anticonvulsant properties all directly enhanced extracellular hippocampal DA or 5-HT levels. Since glutamate-mediated hyperexcitability in temporal lobe regions seems to be involved in disturbed emotional behaviour, we next investigated possible antidepressant effects and hippocampal DA or 5-HT modulations exerted by selective ionotropic and metabotropic glutamate receptor ligands with anticonvulsant properties. Combined anticonvulsant-antidepressant activities of the NMDA antagonist MK-801 and the mGluR group I antagonists (AIDA, MPEP) were also associated with locally elicited increases in hippocampal DA and/or 5-HT levels. This study highlights that the hippocampus is an important site of action of combined anticonvulsant-antidepressant and monoamine enhancing effects.

Collaborative depression care, screening, diagnosis and specificity of depression treatments in the primary care setting

The identification, referral and specific treatment of midlife patients in primary care who are distressed by mood, anxiety, sleep and stress-related symptoms, with or without clinically confirmed menopausal symptoms, are confounded by many structural issues in the delivery of women's healthcare. Diagnosis, care delivery, affordability of treatment, time commitment for treatment, treatment specificity for a particular patient's symptoms and patient receptiveness to diagnosis and treatment all play roles in the successful amelioration of symptoms in this patient population. The value of screening for depression in primary care, the limitations of commonly used screening instruments relative to culture and ethnicity, and which clinical care systems make best use of diagnostic screening programs will be discussed in the context of the midlife woman. The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) program illustrates the relatively high rate of unremitted patients, regardless of clinical setting, who are receiving antidepressants. Nonmedication treatment approaches, referred to in the literature as 'nonsomatic treatments', for depression, anxiety and stress, include different forms of cognitive-behavioral therapy, interpersonal therapy, structured daily activities, mindfulness therapies, relaxation treatment protocols and exercise. The specificity of these treatments, their mechanisms of action, the motivation and time commitment required of patients, and the availability of trained practitioners to deliver them are reviewed. Midlife women with menopausal symptoms and depression/anxiety comorbidity represent a challenging patient population for whom an individualized treatment plan is often necessary. Treatment for depression comorbid with distressing menopausal symptoms would be facilitated by the implementation of a collaborative care program for depression in the primary care setting.

Restoration of impaired phosphorylation of cyclic AMP response element-binding protein (CREB) by EGb 761 and its constituents in Abeta-expressing neuroblastoma cells

Cyclic AMP response element-binding protein (CREB) plays important roles in neuronal plasticity and amyloid beta-peptide (Abeta)-induced cognitive impairment in Alzheimer's disease (AD). Here we demonstrated that Ginkgo biloba extract, EGb 761, displayed the neuron protective effect by activating the CREB signaling pathway. Wild-type neuroblastoma cells cultured in a conditioned medium containing cell-secreted Alphabeta exhibited reduced levels of phosphorylated CREB (pCREB). Addition of EGb 761 (100 microg/mL) or an anti-oligomer-specific antibody (A-11) to the conditioned medium could restore pCREB level. In a neuroblastoma cell line expressing Alphabeta, treatment with EGb 761 increased levels of pCREB and brain-derived neurotrophic factor. Furthermore, CREB phosphorylation induced by EGb 761 was blocked by inhibitors of several upstream signaling pathways of CREB, including protein kinase C, ERK, ribosomal S6 kinase(RSK)90 and nitric oxide pathway. Moreover, these inhibitors differentially blocked the effects of individual components of EGb 761, ginkgolide C, quercetin and bilobalide, which suggest diverse effects of the EGb 761 individual components. Actions of individual EGb 761 components provide further insights into direct mechanisms underlying the effect of EGb 761 on enhancing the cognitive performance of patients with AD.

Effect of levetiracetam on depression and anxiety in adult epileptic patients

BACKGROUND

Interictal depression is common in patients with epilepsy and it significantly impacts quality of life. Some studies indicate that levetiracetam (LEV) may have mood stabilizing properties.

METHODS

Twenty-five adults with uncontrolled partial seizures and concomitant depressive symptoms were treated with LEV. Patients were evaluated for depression and anxiety with several psychometric measures, including: Montgomery and Asberg Depression Rating Scale (MADRS), Hamilton Depression Rating Scale (HDRS), Zung Self-rating Scale for Depression (Z-SDS), Hamilton Anxiety Rating Scale (HARS), Zung Self-rating Scale for Anxiety (Z-SAS).

RESULTS

Evaluations after 5 weeks and after 3 months of LEV treatment demonstrated significant improvement in depression and anxiety.

CONCLUSIONS

This uncontrolled study suggests that treatment with LEV may also improve depression and anxiety in patients with partial seizures. However, the sample of patients is limited and the possibility of a placebo effect cannot be excluded. These findings must be considered preliminary and should be replicated under placebo-controlled conditions.

Multipotent natural agents to combat Alzheimer's disease. Functional spectrum and structural features

With the accelerated aging of human society, Alzheimeros disease (AD) is becoming one of the biggest threats to human health. Since multiple pathogenetic factors are implicated in the disease, the current hitting-one-target therapeutic strategy has proved inefficient to AD. As a result, finding multipotent agents that aim at multiple targets is attracting more and more attention. Although multifunctional anti-AD agents can be created by incorporating two or more pharmacophores in one scaffold, naturally occurring multipotent agents also attracted much attention. In this review, we first describe the functions of some typical naturally originated multipotent anti-AD compounds, then summarize their structural features and reveal that phenolics with certain flexibility predominate in these agents, which are of significance to find novel multipotent drugs to combat AD and other neurodegenerative diseases as well.