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When to Use Amisulpride in Adolescents: A Retrospective Chart Examination of Inpatients. J Clin Psychopharmacol 2022; 42:247-253. [PMID: 35149609 DOI: 10.1097/jcp.0000000000001529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE/BACKGROUND Despite increasing interest in amisulpride, current knowledge about its use in the pediatric population is scarce. This chart review aimed to investigate the use of amisulpride in a naturalistic adolescent population. METHODS/PROCEDURES Electronic medical records of a tertiary care adolescent inpatient unit were screened between January 2015 and April 2021. Sociodemographic data and all clinical information were collected via data collection forms, and targeted symptoms were obtained from patients' files. Patients with early-onset psychotic disorders (n = 58), bipolar I disorder (n = 29), major depressive disorder (n = 14), and other psychiatric diagnoses (n = 9) were included. Treatment response was defined as a Clinical Global Impression-Improvement of at least much improvement after treatment. FINDINGS/RESULTS Median titration rate of amisulpride was 400 mg/wk, and the maximum administered daily dose ranged between 100 and 1200 mg/d. The maximum daily dose and number of previous antipsychotics were higher in the early-onset psychotic disorder group. Persistent positive symptoms and resistance to previous treatments were leading causes for amisulpride treatment. Other indications were also impulsive/disruptive behaviors, antipsychotic adverse effects, depressive symptoms, somatic complaints, and abnormalities in liver function tests. Finally, patients with lower daily treatment doses and more previous antipsychotic trials are less likely to benefit from the treatment. IMPLICATIONS/CONCLUSIONS Persistent psychotic/mood symptoms, impulsive/disruptive behaviors, and abnormalities in liver function tests were reasons for the amisulpride treatment in adolescents. Randomized placebo-controlled trials are needed to evaluate the efficacy and safety of the treatment in adolescents.
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Coronado B, Dunn J, Veronin MA, Reinert JP. Efficacy and Safety Considerations With Second-Generation Antipsychotics as Adjunctive Analgesics: A Review of Literature. J Pharm Technol 2021; 37:202-208. [PMID: 34752579 DOI: 10.1177/87551225211004145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To determine the efficacy and safety of second-generation antipsychotics (SGAs) as adjunctive analgesics. Data Sources: A comprehensive literature review was conducted between August 2020 and January 2021 on PubMed, Scopus, and ProQuest Central. Study Selection and Data Extraction: Keyword and Boolean phrase searches using the following terminology were conducted: "Quetiapine" OR "Risperidone" OR "Olanzapine" OR "Ziprasidone" AND "Analgesia" NOT "Psychosis" NOT "Psych." Articles that involved human adult patients who received any of the SGAs mentioned in the searching filter with an opioid were included. Articles that described pediatrics, pregnant women, patients who received any of these agents for treatment of psychosis and articles that were not in English, or readily translatable to English, were excluded. Data Synthesis: Three articles were selected for inclusion in this review, with 2 articles detailing reports with olanzapine and 1 article describing a randomized, controlled trial with extended-release quetiapine. Both olanzapine and quetiapine were able to decrease pain scores on the numeric rating scale, indicating a reduction pain experienced, and additionally reduced opioid craving behavior in patients. Depression scores and quality-of-life indicators improved with quetiapine, though those metrics were not studied with olanzapine. Conclusions: Select SGAs, specifically extended-release quetiapine and olanzapine, may serve as an appropriate adjunctive analgesic choice in select patients. Further research is required in a clinical setting to determine the exact role of this drug class in pain management.
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Affiliation(s)
| | - Jacob Dunn
- The University of Texas at Tyler, TX, USA
| | | | - Justin P Reinert
- The University of Texas at Tyler, TX, USA.,Bon Secours Mercy Health St. Vincent Medical Center, Toledo, OH, USA
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Zangani C, Giordano B, Stein H, Bonora S, D'Agostino A, Ostinelli EG. Efficacy of amisulpride for depressive symptoms in individuals with mental disorders: A systematic review and meta-analysis. Hum Psychopharmacol 2021; 36:e2801. [PMID: 34727399 PMCID: PMC8596405 DOI: 10.1002/hup.2801] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/15/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Depressive symptoms occur in several psychiatric disorders, often in the absence of a formal diagnosis of depression. We aimed to evaluate the efficacy and the tolerability of amisulpride, both alone and as augmentation therapy, in the treatment of depressive symptoms in individuals with any major psychiatric disorder. METHODS We searched PubMed, Embase, PsycINFO, GreyLit, OpenGrey and ProQuest up to March 2020 for randomised controlled trials focussing on the treatment of an acute depressive episode in any major psychiatric disorder. A random-effect meta-analysis was performed to synthesize the findings on depressive symptoms (primary outcome), response rate and tolerability. RESULTS We retrieved 11 studies including 2065 patients with a diagnosis of dysthymia (eight studies), major depression (one study) or schizophrenia (two studies). Amisulpride 50 mg/day was associated with a larger reduction of depressive symptoms compared to placebo (standardised mean difference [SMD] = -0.70, CI 95% -0.92, -0.49; I2 = 0.0%), and was found to be comparable to selective serotonin reuptake inhibitors (SSRIs; SMD = -0.08, CI 95% -0.23, 0.06, I2 = 0.0%), amineptine, imipramine and amitriptyline in the treatment of dysthymia (three studies, not pooled). In individuals with schizophrenia, amisulpride administered at higher doses (>400 mg/day) was comparable to olanzapine and risperidone (two studies, not pooled). In terms of tolerability, amisulpride was superior to placebo for dysthymia (odds ratio [OR] = 3.94, CI 95% 1.07, 14.48; I2 = 0.0) and comparable with SSRIs (OR = 0.94, CI 95% 0.55, 1.62; I2 = 0.0%). CONCLUSION Treatment with amisulpride could be a valid choice for selected individuals with dysthymia or depressive symptoms in the context of schizophrenia. More studies on the efficacy and tolerability of amisulpride are needed to draw firm conclusions on its potential benefits in other psychiatric disorders.
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Affiliation(s)
- Caroline Zangani
- Oxford Health NHS Foundation Trust, Warneford HospitalOxfordUK,Department of PsychiatryUniversity of OxfordOxfordUK,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research CentreOxfordUK,Department of Health SciencesUniversity of MilanMilanItaly
| | | | | | - Stefano Bonora
- Department of Health SciencesUniversity of MilanMilanItaly
| | | | - Edoardo Giuseppe Ostinelli
- Oxford Health NHS Foundation Trust, Warneford HospitalOxfordUK,Department of PsychiatryUniversity of OxfordOxfordUK,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research CentreOxfordUK
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Tu TTH, Miura A, Shinohara Y, Mikuzuki L, Kawasaki K, Sugawara S, Suga T, Watanabe T, Aota Y, Umezaki Y, Takenoshita M, Toyofuku A. Pharmacotherapeutic outcomes in atypical odontalgia: determinants of pain relief. J Pain Res 2019; 12:831-839. [PMID: 30881094 PMCID: PMC6398971 DOI: 10.2147/jpr.s188362] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES There has been considerable research which has focused on clarifying the origin of pain in patients with atypical odontalgia (AO), also known as "idiopathic toothache", and on identifying effective treatment, but there has been limited success so far. In this study, we assessed the outcomes of treatment and attempted to identify factors that could account for pain remission in patients with AO. PATIENTS AND METHODS Data for 165 patients diagnosed with AO from June 2015 to August 2017 were retrospectively reviewed. The patients' sex, age, duration of pain, and psychiatric history were collected, along with information on pain intensity, depressive status, and catastrophizing scores. Responses at 4 and 16 weeks from the start of treatment were observed. The associations between potentially associated factors and outcome were investigated using Bayesian model averaging. RESULTS A 30% reduction in pain was reported by 38 patients (46.3%) at 4 weeks and by 54 patients (65.9%) at 16 weeks. The pain intensity decreased as the depression and catastrophizing score improved; all of the changes were statistically significant (P<0.001). Four elements, that is, patient sex, depression score at baseline, pain score at 4 weeks, and change in the catastrophizing score, explained 52.5% of the variation in final outcome between individual patients. CONCLUSION Our findings confirm the efficacy of tricyclic antidepressants (TCAs) as a treatment for AO and indicate that other medications, especially aripiprazole used in combination with a TCA, may be useful. A considerable number of patients, especially women, those with lower levels of depression at baseline, and those who responded to 4 weeks of treatment, achieved pain relief.
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Affiliation(s)
- Trang T H Tu
- Department of Psychosomatic Dentistry, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan,
| | - Anna Miura
- Department of Psychosomatic Dentistry, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan,
| | - Yukiko Shinohara
- Department of Psychosomatic Dentistry, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan,
| | - Lou Mikuzuki
- Department of Psychosomatic Dentistry, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan,
| | - Kaoru Kawasaki
- Department of Psychosomatic Dentistry, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan,
| | - Shiori Sugawara
- Department of Psychosomatic Dentistry, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan,
| | - Takayuki Suga
- Department of Psychosomatic Dentistry, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan,
| | - Takeshi Watanabe
- Department of Psychosomatic Dentistry, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan,
| | - Yuma Aota
- Department of Psychosomatic Dentistry, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan,
| | - Yojiro Umezaki
- Department of Geriatric Dentistry, Fukuoka Dental College, Fukuoka, Japan
| | - Miho Takenoshita
- Department of Psychosomatic Dentistry, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan,
| | - Akira Toyofuku
- Department of Psychosomatic Dentistry, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan,
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Abstract
Chronic pain is a frequent condition that affects an estimated 20% of people worldwide, accounting for 15%-20% of doctors' appointments (Treede et al., 2015). It lacks the acute warning function of physiologic nociception, and instead involves the activation of multiple neurophysiologic mechanisms in the somatosensory system, a complex neuronal network under the control of powerful autoregulatory loops and able to undergo rapid neuroplastic alteration (Verdu et al., 2008). There is a growing body of research suggesting that some such pathways are shared by major psychologic disorders such as depression and anxiety, opening new avenues in co-treatment strategies. In particular, besides anticonvulsants, which are today used as analgesics, other psychopharmaceuticals, such as the tricyclic antidepressants, are displaying efficacy in the treatment of neuropathic and nociceptive chronic pain. The state of the art regarding the mechanisms of nociception and the pharmacology of both the neurotransmitters involved and the wide range of psychoactive compounds that may be useful in the treatment of chronic pain are discussed.
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Drossman DA, Tack J, Ford AC, Szigethy E, Törnblom H, Van Oudenhove L. Neuromodulators for Functional Gastrointestinal Disorders (Disorders of Gut-Brain Interaction): A Rome Foundation Working Team Report. Gastroenterology 2018; 154:1140-1171.e1. [PMID: 29274869 DOI: 10.1053/j.gastro.2017.11.279] [Citation(s) in RCA: 210] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 11/13/2017] [Accepted: 11/24/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Central neuromodulators (antidepressants, antipsychotics, and other central nervous system-targeted medications) are increasingly used for treatment of functional gastrointestinal disorders (FGIDs), now recognized as disorders of gut-brain interaction. However, the available evidence and guidance for the use of central neuromodulators in these conditions is scanty and incomplete. In this Rome Foundation Working Team report, a multidisciplinary team summarized available research evidence and clinical experience to provide guidance and treatment recommendations. METHODS The working team summarized the literature on the pharmacology of central neuromodulators and their effects on gastrointestinal sensorimotor function and conducted an evidence-based review on their use for treating FGID syndromes. Because of the paucity of data for FGIDs, we included data for non-gastrointestinal painful disorders and specific symptoms of pain, nausea, and vomiting. This information was combined into a final document comprising a synthesis of available evidence and recommendations for clinical use guided by the research and clinical experience of the experts on the committee. RESULTS The evidence-based review on neuromodulators in FGID, restricted by the limited available controlled trials, was integrated with open-label studies and case series, along with the experience of experts to create recommendations using a consensus (Delphi) approach. Due to the diversity of conditions and complexity of treatment options, specific recommendations were generated for different FGIDs. However, some general recommendations include: (1) low to modest dosages of tricyclic antidepressants provide the most convincing evidence of benefit for treating chronic gastrointestinal pain and painful FGIDs and serotonin noradrenergic reuptake inhibitors can also be recommended, though further studies are needed; (2) augmentation, that is, adding a second treatment (adding quetiapine, aripiprazole, buspirone α2δ ligand agents) is recommended when a single medication is unsuccessful or produces side effects at higher dosages; (3) treatment should be continued for 6-12 months to potentially prevent relapse; and (4) implementation of successful treatment requires effective communication skills to improve patient acceptance and adherence, and to optimize the patient-provider relationship. CONCLUSIONS Based on systematic and selectively focused review and the consensus of a multidisciplinary panel, we have provided summary information and guidelines for the use of central neuromodulators in the treatment of chronic gastrointestinal symptoms and FGIDs. Further studies are needed to confirm and refine these recommendations.
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Affiliation(s)
- Douglas A Drossman
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina; Center for Education and Practice of Biopsychosocial Care and Drossman Gastroenterology, Chapel Hill, North Carolina.
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
| | - Alexander C Ford
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom; Leeds Gastroenterology Institute, St James's University Hospital, Leeds, United Kingdom
| | - Eva Szigethy
- Departments of Psychiatry and Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hans Törnblom
- Departments of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lukas Van Oudenhove
- Laboratory for Brain-Gut Axis Studies, Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
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Seidel S, Aigner M, Wildner B, Sycha T, Pablik E. Antipsychotics for the treatment of neuropathic pain in adults. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2018. [DOI: 10.1002/14651858.cd012916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Stefan Seidel
- Medical University of Vienna; Department of Neurology; Währinger Straße 13a Vienna Austria
| | - Martin Aigner
- Medical University of Vienna; Department of Psychiatry; Währinger Gürtel 18-20 Vienna Austria AT-1090
| | - Brigitte Wildner
- University Library of the Medical University of Vienna; Information Retrieval Office; Währinger Gürtel 18-20 Vienna Austria 1090
| | - Thomas Sycha
- Medical University of Vienna; Department of Neurology; Währinger Straße 13a Vienna Austria
| | - Eleonore Pablik
- Medical University of Vienna; CeMSIIS, Section for Medical Statistics; Vienna Austria
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8
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Barygin OI, Nagaeva EI, Tikhonov DB, Belinskaya DA, Vanchakova NP, Shestakova NN. Inhibition of the NMDA and AMPA receptor channels by antidepressants and antipsychotics. Brain Res 2017; 1660:58-66. [PMID: 28167075 DOI: 10.1016/j.brainres.2017.01.028] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 01/18/2017] [Accepted: 01/19/2017] [Indexed: 12/22/2022]
Abstract
It is known that some antidepressants and antipsychotics directly inhibit NMDA-type ionotropic glutamate receptors. In this study we systematically studied action of seven drugs (Fluoxetine, Citalopram, Desipramine, Amitriptyline, Atomoxetine, Chlorpromazine, and Clozapine) on NMDA receptors and Ca2+-permeable and -impermeable AMPA receptors in rat brain neurons by whole-cell patch-clamp technique. Except for weak effect of fluoxetine, all drugs were virtually inactive against Ca2+-impermeable AMPA receptors. Fluoxetine and desipramine significantly inhibited Ca2+-permeable AMPA receptors (IC50=43±7 and 105±12µM, respectively). Desipramine, atomoxetine and chlorpromazine inhibited NMDA receptors in clinically relevant low micromolar concentrations, while citalopram had only weak effect. All tested medicines have been clustered into two groups by their action on NMDA receptors: desipramine, amitriptyline, chlorpromazine, and atomoxetine display voltage- and magnesium-dependent open channel blocking mechanism. Action of fluoxetine and clozapine was found to be voltage- and magnesium-independent. All voltage-dependent compounds could be trapped in closed NMDA receptor channels. Possible contribution of NMDA receptor inhibition by certain antidepressants and antipsychotics to their analgesic effects in neuropathic pain is discussed.
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Affiliation(s)
- Oleg I Barygin
- I.M. Sechenov Institute of Evolutionary Physiology and Biochemistry RAS, Saint-Petersburg, Russia.
| | - Elina I Nagaeva
- I.M. Sechenov Institute of Evolutionary Physiology and Biochemistry RAS, Saint-Petersburg, Russia
| | - Denis B Tikhonov
- I.M. Sechenov Institute of Evolutionary Physiology and Biochemistry RAS, Saint-Petersburg, Russia
| | - Darya A Belinskaya
- I.M. Sechenov Institute of Evolutionary Physiology and Biochemistry RAS, Saint-Petersburg, Russia
| | - Nina P Vanchakova
- I.M. Sechenov Institute of Evolutionary Physiology and Biochemistry RAS, Saint-Petersburg, Russia
| | - Natalia N Shestakova
- I.M. Sechenov Institute of Evolutionary Physiology and Biochemistry RAS, Saint-Petersburg, Russia
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Arout CA, Sofuoglu M, Rosenheck RA. Rates and Correlates of Pain Specialty Clinic Use Nationally in the Veterans Health Administration. PAIN MEDICINE 2017; 18:702-710. [DOI: 10.1093/pm/pnw206] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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10
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Törnblom H, Drossman DA. Centrally Targeted Pharmacotherapy for Chronic Abdominal Pain: Understanding and Management. Handb Exp Pharmacol 2017; 239:417-440. [PMID: 28204956 DOI: 10.1007/164_2016_106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Chronic abdominal pain has a widespread impact on the individual and the society. Identifying and explaining mechanisms of importance for the pain experience within a biopsychosocial context are central in order to select treatment that has a chance for symptom reduction. With current knowledge of brain-gut interactions, chronic abdominal pain, which mostly appears in functional gastrointestinal disorders, to a large extent involves pain mechanisms residing within the brain. As such, the use of centrally targeted pharmacotherapy as an effective treatment option is obvious in a selected number of patients. The antidepressants are most common, but also other classes of medications can be used, either alone or in combination. The latter option refers to when there is insufficient effect of one drug alone or side effects limiting dosage, and when combined in lower doses, certain drugs give rise to augmentation effects. This chapter outlines basic mechanisms of importance for the understanding of chronic abdominal pain and the pharmacologic treatment options.
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Affiliation(s)
- Hans Törnblom
- Dept of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, SE-41345, Gothenburg, Sweden.
| | - Douglas A Drossman
- Drossman Center for the Education and Practice of Biopsychosocial Care, Professor Emeritus of Medicine and Psychiatry, UNC Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Drossman Gastroenterology PLLC, Chapel Hill, NC, USA
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Cheatle MD, Foster S, Pinkett A, Lesneski M, Qu D, Dhingra L. Assessing and Managing Sleep Disturbance in Patients with Chronic Pain. Sleep Med Clin 2016; 11:531-541. [DOI: 10.1016/j.jsmc.2016.08.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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12
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Abstract
BACKGROUND This review is one of a series on drugs used to treat fibromyalgia. Fibromyalgia is a clinically well-defined chronic condition of unknown aetiology characterised by chronic widespread pain that often co-exists with sleep problems and fatigue. It affects approximately 2% of the general population. Up to 70% of patients with fibromyalgia meet the criteria for a depressive or anxiety disorder. People often report high disability levels and poor health-related quality of life. Drug therapy focuses on reducing key symptoms and disability, and improving health-related quality of life. Antipsychotics might reduce fibromyalgia and associated mental health symptoms. OBJECTIVES To assess the efficacy, tolerability and safety of antipsychotics in fibromyalgia in adults. SEARCH METHODS We searched CENTRAL (2016, Issue 4), MEDLINE and EMBASE to 20 May 2016, together with reference lists of retrieved papers and reviews and two clinical trial registries. We also contacted trial authors. SELECTION CRITERIA We selected controlled trials of at least four weeks duration of any formulation of antipsychotics used for the treatment of fibromyalgia in adults. DATA COLLECTION AND ANALYSIS We extracted the data from all included studies and two review authors independently assessed study risks of bias. We resolved discrepancies by discussion. We performed analysis using three tiers of evidence. We derived first tier evidence from data meeting current best standards and subject to minimal risk of bias (outcome equivalent to substantial pain intensity reduction, intention-to-treat analysis without imputation for drop-outs, at least 200 participants in the comparison, eight to 12 weeks duration, parallel design), second tier evidence from data that failed to meet one or more of these criteria and that we considered at some risk of bias but with adequate numbers in the comparison, and third tier evidence from data involving small numbers of participants that we considered very likely to be biased or used outcomes of limited clinical utility, or both. We rated the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We included a total of four studies with 296 participants.Three studies with 206 participants compared quetiapine, an atypical (second-generation) antipsychotic, with placebo. One study used a cross-over design and two studies a parallel-group design. Study duration was eight or 12 weeks. Quetiapine was used in all studies with a bedtime dosage between 50 and 300 mg/day. All studies had one or more sources of potential major bias and we judged them to be at moderate risk of bias overall. The primary outcomes in this review were participant-reported pain relief of 50% or greater, Patient Global Impression of Change (PGIC) much or very much improved, withdrawal due to adverse events (tolerability) and serious adverse events (safety).Second tier evidence indicated that quetiapine was not statistically superior to placebo in the number of participants with a 50% or more pain reduction (very low quality evidence). No study reported data on PGIC. A greater proportion of participants on quetiapine reported a 30% or more pain reduction (risk difference (RD) 0.12, 95% confidence interval (CI) 0.00 to 0.23; number needed to treat for an additional benefit (NNTB) 8, 95% CI 5 to 100) (very low quality evidence). A greater proportion of participants on quetiapine reported a clinically relevant improvement of health-related quality of life compared to placebo ( RD 0.18, 95% CI 0.05 to 0.31; NNTB 5, 95% CI 3 to 20) (very low quality evidence). Quetiapine was statistically superior to placebo in reducing sleep problems (standardised mean difference (SMD) -0.67, 95% CI -1.10 to -0.23), depression (SMD -0.39, 95% CI -0.74 to -0.04) and anxiety (SMD -0.40, 95% CI -0.69 to -0.11) (very low quality evidence). Quetiapine was statistically superior to placebo in reducing the risk of withdrawing from the study due to a lack of efficacy (RD -0.14, 95% CI -0.23 to -0.05) (very low quality evidence). There was no statistically significant difference between quetiapine and placebo in the proportion of participants withdrawing due to adverse events (tolerability) (very low quality evidence), in the frequency of serious adverse events (safety) (very low quality evidence) and in the proportion of participants reporting dizziness and somnolence as an adverse event (very low quality evidence). In more participants in the quetiapine group a substantial weight gain was noted (RD 0.08, 95% CI 0.02 to 0.15; number needed to treat for an additional harm (NNTH) 12, 95% CI 6 to 50) (very low quality evidence). We downgraded the quality of evidence by three levels to a very low quality rating because of limitations of study design, indirectness (patients with major medical diseases and mental disorders were excluded) and imprecision (fewer than 400 patients were analysed).One parallel design study with 90 participants compared quetiapine (50 to 300 mg/day flexible at bedtime) to amitriptyline (10 to 75 mg/day flexible at bedtime). The study had three major risks of bias and we judged it to be at moderate risk of bias overall. We downgraded the quality of evidence by two levels to a low quality rating because of indirectness (patients with major medical diseases and mental disorders were excluded) and imprecision (fewer than 400 patients were analysed). Third tier evidence indicated no statistically significant differences between the two drugs. Both drugs did not statistically significantly differ in the reduction of average scores for pain, fatigue, sleep problems, depression, anxiety and for limitations of health-related quality of life and in the proportion of participants reporting dizziness, somnolence and weight gain as a side effect (low quality evidence). Compared to amitriptyline, more participants left the study due to adverse events (low quality evidence). No serious adverse events were reported (low quality evidence).We found no relevant study with other antipsychotics than quetiapine in fibromyalgia. AUTHORS' CONCLUSIONS Very low quality evidence suggests that quetiapine may be considered for a time-limited trial (4 to 12 weeks) to reduce pain, sleep problems, depression and anxiety in fibromyalgia patients with major depression. Potential side effects such as weight gain should be balanced against the potential benefits in shared decision making with the patient.
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Affiliation(s)
- Brian Walitt
- National Institutes of HealthNational Center for Complementary and Integrative Health10 Center DriveBethesdaMDUSA20892
- National Institutes of HealthNational Institute of Nursing Research10 Center DriveBethesdaMDUSA20892
| | - Petra Klose
- University of Duisburg‐EssenDepartment of Internal and Integrative Medicine, Kliniken Essen‐Mitte, Faculty of MedicineAm Deimelsberg 34 aEssenGermanyD‐45276
| | - Nurcan Üçeyler
- University of WürzburgDepartment of NeurologyWürzburgGermany97080
| | - Tudor Phillips
- University of OxfordPain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics)Churchill HospitalOxfordUKOX3 7LJ
| | - Winfried Häuser
- Technische Universität MünchenDepartment of Psychosomatic Medicine and PsychotherapyLangerstr. 3MünchenGermanyD‐81675
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Cheatle MD, Foster S, Pinkett A, Lesneski M, Qu D, Dhingra L. Assessing and Managing Sleep Disturbance in Patients with Chronic Pain. Anesthesiol Clin 2016; 34:379-393. [PMID: 27208716 DOI: 10.1016/j.anclin.2016.01.007] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Chronic pain is associated with symptoms that may impair a patient's quality of life, including emotional distress, fatigue, and sleep disturbance. There is a high prevalence of concomitant pain and sleep disturbance. Studies support the hypothesis that sleep and pain have a bidirectional and reciprocal relationship. Clinicians who manage patients with chronic pain often focus on interventions that relieve pain, and assessing and treating sleep disturbance are secondary or not addressed. This article reviews the literature on pain and co-occurring sleep disturbance, describes the assessment of sleep disturbance, and outlines nonpharmacologic and pharmacologic treatment strategies to improve sleep in patients with chronic pain.
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Affiliation(s)
- Martin D Cheatle
- Department of Psychiatry, Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 4th Floor, Philadelphia, PA 19104, USA; Department of Psychiatry, Behavioral Medicine Center, Reading Health System, 560 Van Reed Road, Suite 204, Wyomissing, PA 19610, USA.
| | - Simmie Foster
- Kirby Center for Neurobiology, 3 Blackfan Circle, CLS 12-260, Boston, MA 02115, USA
| | - Aaron Pinkett
- Department of Psychiatry, Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 4th Floor, Philadelphia, PA 19104, USA
| | - Matthew Lesneski
- RA Pain Services, 1500 Midatlantic Drive Suite 102, Mount Laurel, NJ 0854, USA
| | - David Qu
- Highpoint Pain and Rehabilitation Physicians P.C., 700 Horizon Circle Suite 206, Chalfont, PA 18914, USA
| | - Lara Dhingra
- MJHS Institute for Innovation in Palliative Care, 39 Broadway, 3rd Floor, New York, NY 10006, USA
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Albrecht PJ, Rice FL. Fibromyalgia syndrome pathology and environmental influences on afflictions with medically unexplained symptoms. REVIEWS ON ENVIRONMENTAL HEALTH 2016; 31:281-294. [PMID: 27105483 DOI: 10.1515/reveh-2015-0040] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 03/10/2016] [Indexed: 06/05/2023]
Abstract
Fibromyalgia syndrome (FMS) is a clinical disorder predominant in females with unknown etiology and medically unexplained symptoms (MUS), similar to other afflictions, including irritable bowel syndrome (IBS), chronic fatigue syndrome (CFS), post-traumatic stress disorder (PTSD), Gulf War illness (GFI), and others. External environmental stimuli drive behavior and impact physiologic homeostasis (internal environment) via autonomic functioning. These environments directly impact the individual affective state (mind), which feeds back to regulate physiology (body). FMS has emerged as a complex disorder with pathologies identified among neurotransmitter and enzyme levels, immune/cytokine functionality, cortical volumes, cutaneous innervation, as well as an increased frequency among people with a history of traumatic and/or emotionally negative events, and specific personality trait profiles. Yet, quantitative physical evidence of pathology or disease etiology among FMS has been limited (as with other afflictions with MUS). Previously, our group published findings of increased peptidergic sensory innervation associated with the arterio-venous shunts (AVS) in the glabrous hand skin of FMS patients, which provides a plausible mechanism for the wide-spread FMS symptomology. This review focuses on FMS as a model affliction with MUS to discuss the implications of the recently discovered peripheral innervation alterations, explore the role of peripheral innervation to central sensitization syndromes (CSS), and examine possible estrogen-related mechanisms through which external and internal environmental factors may contribute to FMS etiology and possibly other afflictions with MUS.
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Abstract
Chronic pain is considered one of the most prevalent causes of costly and disabling medical conditions. This review will define chronic pain and its categories and then will summarize the effectiveness and side effects associated with the use of various antidepressants, including the tricyclics, the selective serotonin reuptake inhibitors, the serotonin norepinephrine reuptake inhibitors, other miscellaneous antidepressants and the atypical antipsychotics in the treatment of chronic pain.
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Affiliation(s)
- Hani Raoul Khouzam
- a Department of Psychiatry , Dartmouth -Hitchcock Medical Center, One Medical Center Drive , Lebanon , NH , USA
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Törnblom H, Drossman DA. Centrally targeted pharmacotherapy for chronic abdominal pain. Neurogastroenterol Motil 2015; 27:455-67. [PMID: 25651186 DOI: 10.1111/nmo.12509] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 12/14/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic abdominal pain in the context of the functional gastrointestinal disorders departs from a more traditional approach to treating gastrointestinal symptoms. Chronic abdominal pain involves a dysregulation of brain-gut modulation of afferent signaling, so treatments directed toward the gut are not usually sufficient to achieve a clinical response. Rather the methods of treatment depend on re-establishing central pain regulation. PURPOSE A conceptual model of predisposing, precipitating, and perpetuating factors is used to explain how a situation of chronic pain develops and it provides the evidence for central neuron degeneration as relevant to this chain of events. The rationale for centrally targeted medications, in particular antidepressants, is discussed with regard to effects independent of their role in treating psychiatric disorders: with regard to downregulation of afferent pain signals and their potential role in neuron proliferation. Finally, guiding examples of which drug to use and treatment combinations involving multiple drugs, augmentation treatment, are outlined and some brief clinical cases of centrally targeted pharmacotherapy.
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Affiliation(s)
- H Törnblom
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Calandre EP, Rico-Villademoros F, Galán J, Molina-Barea R, Vilchez JS, Rodriguez-Lopez CM, Hidalgo-Tallon J, Morillas-Arques P. Quetiapine extended-release (Seroquel-XR) versus amitriptyline monotherapy for treating patients with fibromyalgia: a 16-week, randomized, flexible-dose, open-label trial. Psychopharmacology (Berl) 2014; 231:2525-31. [PMID: 24398824 DOI: 10.1007/s00213-013-3422-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 12/16/2013] [Indexed: 10/25/2022]
Abstract
RATIONALE Previous open-label studies have suggested that quetiapine could be a valuable alternative for treating fibromyalgia. OBJECTIVE This study aims to compare the efficacy and tolerability of extended-release quetiapine with amitriptyline for treating fibromyalgia. METHODS This study was a randomized, open-label, flexible-dose, non-inferiority trial. Patients with fibromyalgia were randomized to receive quetiapine extended-release (XR) (N = 45) (50 to 300 mg daily) or amitriptyline (N = 45) (10 to 75 mg daily) for 16 weeks. The primary endpoint was the change from baseline to endpoint in the Fibromyalgia Impact Questionnaire (FIQ) total score; the non-inferiority threshold was established at 8 points. The secondary outcomes included sleep quality, anxiety, depression, and quality of life. RESULTS Twenty-two (49%) patients in the quetiapine group and 34 (76%) patients in the amitriptyline group completed the study. We found a reduction of 9.8 points in the total FIQ score at the endpoint for the quetiapine-treated patients compared to 13.9 points for the amitriptyline-treated patients, for a difference of 4.14 points (80% confidence interval (CI) -0.70 to 8.98). No significant differences were found between the quetiapine XR and amitriptyline groups for any of the secondary outcomes. The proportion of patients discontinuing treatment due to adverse events was higher in the quetiapine group (n = 14, 31.1%) than the amitriptyline group (n = 3, 6.6%). CONCLUSIONS Our results appear to indicate that quetiapine XR does not provide similar efficacy to amitriptyline for treating patients with fibromyalgia. Quetiapine XR had a worse tolerability than amitriptyline in this population, possibly due to a relatively high starting dose.
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Affiliation(s)
- Elena P Calandre
- Instituto de Neurociencias, Universidad de Granada, Avenida de Madrid 11, Granada, Spain,
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McIntyre A, Paisley D, Kouassi E, Gendron A. Quetiapine fumarate extended-release for the treatment of major depression with comorbid fibromyalgia syndrome: a double-blind, randomized, placebo-controlled study. Arthritis Rheumatol 2014; 66:451-61. [PMID: 24504819 DOI: 10.1002/art.38228] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Accepted: 10/08/2013] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Fibromyalgia and major depressive disorder (MDD) frequently co-occur. Quetiapine fumarate extended-release (quetiapine XR) has demonstrated efficacy in the treatment of MDD and has been shown to have analgesic properties in patients with depression. The primary objectives of this study were to evaluate the effects of quetiapine XR on depressive and pain symptoms in patients with MDD and comorbid fibromyalgia, and to assess its safety and tolerability. METHODS This was an 8-week, single-center, double-blind, randomized, controlled trial. A total of 120 nonpsychotic adult outpatients who fulfilled the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnostic criteria for MDD and whose diagnosis of fibromyalgia was confirmed according to the American College of Rheumatology criteria were enrolled. The primary end point was the mean change from baseline to week 8 on the 17-item Hamilton Depression Rating (HAM-D) scale. Secondary end points included other depression-rating scores, pain scores, fibromyalgia scores, measures of quality of life and global functioning, and adverse events. RESULTS The mean change in the HAM-D score from baseline to week 8 was significantly greater in the quetiapine XR group compared with the placebo group (-10.0 versus -5.8; P = 0.001). Improvements in most secondary outcomes were also significantly greater in the quetiapine XR group. Quetiapine XR was generally well tolerated. CONCLUSION This study is the first to demonstrate that measures of depression, pain, and quality of life are significantly improved with quetiapine XR compared with placebo in patients with a dual diagnosis of MDD and fibromyalgia.
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Häuser W, Walitt B, Fitzcharles MA, Sommer C. Review of pharmacological therapies in fibromyalgia syndrome. Arthritis Res Ther 2014; 16:201. [PMID: 24433463 PMCID: PMC3979124 DOI: 10.1186/ar4441] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 01/09/2014] [Indexed: 12/16/2022] Open
Abstract
This review addresses the current status of drug therapy for the management of fibromyalgia syndrome (FMS) and is based on interdisciplinary FMS management guidelines, meta-analyses of drug trial data, and observational studies. In the absence of a single gold-standard medication, patients are treated with a variety of drugs from different categories, often with limited evidence. Drug therapy is not mandatory for the management of FMS. Pregabalin, duloxetine, milnacipran, and amitriptyline are the current first-line prescribed agents but have had a mostly modest effect. With only a minority of patients expected to experience substantial benefit, most will discontinue therapy because of either a lack of efficacy or tolerability problems. Many drug treatments have undergone limited study and have had negative results. It is unlikely that these failed pilot trials will undergo future study. However, medications, though imperfect, will continue to be a component of treatment strategy for these patients. Both the potential for medication therapy to relieve symptoms and the potential to cause harm should be carefully considered in their administration.
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Faure D, Giniès P, Eiden C, Portet L, Peyrière H. Opioïdes forts dans le traitement des douleurs chroniques non cancéreuses : analyse rétrospective de patients pris en charge pour un sevrage. Therapie 2013; 68:385-92. [DOI: 10.2515/therapie/2013066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 09/05/2013] [Indexed: 11/20/2022]
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Chronic pain treatment: the influence of tricyclic antidepressants on serotonin release and uptake in mast cells. Mediators Inflamm 2013; 2013:340473. [PMID: 23710115 PMCID: PMC3654333 DOI: 10.1155/2013/340473] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 04/02/2013] [Indexed: 12/11/2022] Open
Abstract
The involvement of serotonin (5-HT) in chronic pain mechanisms is established. 5-HT inhibits central painful stimuli, but recent data suggests that 5-HT could also enhance pain stimulus from the periphery, where mast cells play an important role. We aimed in our study to clarify the influence of selected tricyclic antidepressants (TCAs) on mast cell function: secretion, uptake, and reuptake of 5-HT, that could interfere with 5-HT levels and in this way contribute to the generation of pain. As an experimental model, we used isolated rat peritoneal mast cells and incubated them with selected TCAs (clomipramine, amitriptyline, doxepin, and imipramine) under different experimental conditions. 5-HT release, uptake, and reuptake were determined spectrofluorometrically. We showed that TCAs were able to inhibit 5-HT secretion from mast cells, as well as uptake of exogenous 5-HT and reuptake of secreted 5-HT back into mast cells. The effects of TCAs were concentration dependent; higher concentrations of TCAs inhibited the secretion of 5-HT induced by compound 48/80, whereas lower concentrations of TCAs inhibited 5-HT uptake. The most effective TCA was halogenated clomipramine. As TCAs are well introduced in chronic pain treatment, the insight into mechanisms of action is important for an understanding of their effect in various pain conditions.
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Pae CU, Lee SJ, Han C, Patkar AA, Masand PS. Atypical antipsychotics as a possible treatment option for irritable bowel syndrome. Expert Opin Investig Drugs 2013; 22:565-72. [PMID: 23506326 DOI: 10.1517/13543784.2013.782392] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Irritable bowel syndrome (IBS) is a prevalent functional gastrointestinal disorder (FGID) that is characterised by chronic abdominal pain, discomfort, bloating, and alteration of bowel habits. Although the pathophysiology of IBS is not fully understood, it is believed that psychiatric comorbidities are highly common in such patients. A variety of psychotropic medications are widely used in the treatment of IBS, particularly older antidepressants such as tricyclic antidepressants (TCAs). AREAS COVERED With the advent of newer antidepressant classes with better safety and tolerability compared with TCAs, such as serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), clinicians now have more advanced treatment options for treating IBS. Additionally, some atypical antipsychotics (AAs) have recently received approval for treatment of major depressive disorder (MDD). Some AAs may have potentials based on their pharmacodynamic profile and proven benefit for mood symptoms, pain, anxiety and sleep disturbances. This article describes the potential rationale, clinical data and practical aspects involved in the use of AAs for patients with IBS. EXPERT OPINION Atypical antipsychotics (AAs) may have a role in the treatment of irritable bowel syndrome (IBS) based on the currently available findings, although there is no clear evidence, and a number of clinical issues to be addressed in the use of AAs for the treatment of IBS.
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Affiliation(s)
- Chi-Un Pae
- The Catholic University of Korea College of Medicine, Bucheon St Mary's Hospital, Department of Psychiatry, 2 Sosa-Dong, Wonmi-Gu, Bucheon, Kyeonggi-Do 420-717, Republic of Korea.
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Dekel R, Drossman DA, Sperber AD. The use of psychotropic drugs in irritable bowel syndrome. Expert Opin Investig Drugs 2013; 22:329-39. [PMID: 23316916 DOI: 10.1517/13543784.2013.761205] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Irritable bowel syndrome (IBS), the most common functional gastrointestinal disorder, is manifested by chronic abdominal pain associated with irregular bowel movements. Although not life threatening, IBS is associated with impaired quality of life that ranges from mild to severe. AREAS COVERED The pathogenesis of IBS is not completely understood, but involves dysfunction of the "brain-gut axis" including peripheral visceral hypersensitivity and central maladaptive processing of visceral pain input. Stress and concomitant psychopathologies such as somatization, anxiety and depression are thought to play a major role in the development, clinical course and response to treatment. Psychopharmacological agents such as selective serotonin/serotonin-norepinephrine receptor antagonists, tricyclic antidepressants as well as other agents are commonly used in treating moderate to severe IBS. This review will provide the pathophysiological rationale for the use of psychopharmacological agents in IBS, review the main classes of drugs and evidence for their use in IBS and offer a practical approach to the use of these drugs. EXPERT OPINION Psychotropic drugs can play a pivotal role in the treatment of IBS patients, so doctors should be familiar with their use. Further research with these drugs is needed to solidify our current knowledge and increase our therapeutic options.
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Affiliation(s)
- Roy Dekel
- Tel Aviv Medical Center, Gastroenterology, Tel Aviv, Israel.
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&NA;. Antipsychotics are among the psychoactive medications that may prove to be of benefit in treating fibromyalgia. DRUGS & THERAPY PERSPECTIVES 2012. [DOI: 10.2165/11608680-000000000-00000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Antipsychotics are among the psychoactive medications that may prove to be of benefit in treating fibromyalgia. DRUGS & THERAPY PERSPECTIVES 2012. [DOI: 10.1007/bf03262135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Amisulpride in the treatment of fibromyalgia: an uncontrolled study. Clin Rheumatol 2012; 31:1371-5. [DOI: 10.1007/s10067-012-2012-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2012] [Revised: 04/06/2012] [Accepted: 05/21/2012] [Indexed: 11/25/2022]
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