Water-soluble vitamins and trace elements in children with chronic kidney disease stage 5d

Children receiving maintenance dialysis (chronic kidney disease (CKD) stage 5d) have unique risk factors for micronutrient deficiency or toxicity. Children receiving chronic dialysis often require specialized diet plans that may provide more than the recommended daily allowance (RDA) of water-soluble vitamins and micronutrients, with or without the addition of a kidney-friendly vitamin. The following is a comprehensive review of current literature on disorders of micronutrients in this population including those of water-soluble vitamins (vitamin C and vitamin B complexes) and trace elements (copper, selenium, and zinc) and has three areas of focus: (1) the risk factors and clinical presentations of disorders of micronutrients, both deficiency and toxicity, (2) the tools to evaluate micronutrient status, and (3) the central role of renal dietitians in optimizing nutritional status from a micronutrient perspective.

Effect of lycopene supplementation to bovine oocytes exposed to heat shock during in vitro maturation

We investigated the effect of the antioxidant lycopene supplemented into the in vitro maturation medium (TCM-199 with 20 ng/mL epidermal growth factor and 50 mg/mL gentamycin) in a heat shock (HS) model to mimic in vivo heat stress conditions. Bovine cumulus-oocyte complexes were supplemented with 0.2 μM lycopene (or not supplemented; control) under HS (40.5 °C) and non-HS (NHS; 38.5 °C) during maturation. After 22 h of maturation, we evaluated the nuclear status of the oocytes, the level of reactive oxygen species (ROS) production, and the respective blastocyst development and quality (via differential staining). Data were fitted in logistic and linear regression models, and the replicates were set as a random effect. The nuclear maturation was higher in NHS (84.0 ± 3.2%; least square mean ± standard error) than HS control (60.4 ± 4.3%; P < 0.001). Remarkably, the nuclear maturation in HS lycopene (71.7 ± 4.1%) was similar to NHS control (P = 0.7). Under HS conditions lycopene reduced ROS production (27.4 ± 4.8; relative fluorescence units (RFU)) in comparison to HS control (33.8 ± 1.8 RFU; P = 0.009). However, the ROS production in NHS lycopene (18.9 ± 2.0 RFU) was similar to NHS control (18.7 ± 1.8 RFU; P = 0.9). The cleavage rate in HS lycopene (76.1 ± 3.3%) was not lower than NHS lycopene (83.3 ± 2.5%; P > 0.1). On the day 8 of embryo development, the blastocyst rate was higher for NHS lycopene (55.2 ± 4.7%) versus NHS control (44.5 ± 4.7%; P = 0.04), but under HS the day 8 blastocyst rate was similar between control (29.9 ± 4.2%) and lycopene (32.3 ± 4.2%; P = 0.9). Lycopene supplementation increased the cell number of the embryos (total cell, trophectoderm, and inner cell mass numbers) under NHS conditions (P > 0.03). The apoptotic cell ratio was lower in lycopene (NHS and HS) versus control (NHS and HS) (P > 0.04). Lycopene has the ability to scavenge oocyte ROS and improved the cleavage rate of embryos under HS conditions. However, this could not be translated to a higher blastocyst development, which remained lower under HS. Results of our study indicate that antioxidant supplementation like lycopene during the maturation of bovine cumulus-oocyte complexes may be routinely used to improve blastocyst rate and quality under standard maturation conditions.

A Novel Tool for the Early Identification of Frailty in Elderly People: The Application in Primary Care Settings

BACKGROUND

Frailty is a pre-disability condition in older persons providing a challenge to Health-Care Systems. Systematic reviews highlight the absence of a gold-standard for its identification. However, an approach based on initial screening by the General Practitioner (GP) seems particularly useful. On these premises, a 9-item Sunfrail Checklist (SC), was developed by a multidisciplinary group, in the context of European Sunfrail Project, and tested in the Community.

OBJECTIVES

- to measure the concordance between the judgments of frailty (criterion-validity): the one formulated by the GP, using the SC, and the one subsequently expressed by a Comprehensive Geriatric Assessment Team (CGA-Team); - to determine the construct-validity through the correspondence between some checklist items related to the 3 domains (physical, cognitive and social) and the three tools used by the CGA-Team; - to measure the instrument's performance in terms of positive predictive value (PPV) and negative predictive value (NPV).

DESIGN

Cross-sectional study, with a final sample-size of 95 subjects.

SETTING

Two Community-Health Centers of Parma, Italy.

PARTICIPANTS

Subjects aged 75 years old or more, with no disability and living in the community.

MEASUREMENTS

We compared the screening capacity of the GP using the SC to that one of CGA-Team based on three tests: 4-meter Gait-Speed, Mini-Mental State Examination and Loneliness Scale.

RESULTS

95 subjects (51 women), with a mean age of 81±4 years were enrolled. According to GPs 34 subjects were frail; the CGA-Team expressed a frailty judgment on 26 subjects. The criterion-validity presented a Cohen's k of 0.353. Construct-validity was also low, with a maximum contingency-coefficient of 0.19. The analysis showed a PPV of 58.1% and a NPV equal to 84.6%.

CONCLUSIONS

Our data showed a low agreement between the judgements of GP performed by SC and CGA-Team. However, the good NPV suggests the applicability of SC for screening activities in primary-care.

Petawatt Laser Guiding and Electron Beam Acceleration to 8 GeV in a Laser-Heated Capillary Discharge Waveguide

Guiding of relativistically intense laser pulses with peak power of 0.85 PW over 15 diffraction lengths was demonstrated by increasing the focusing strength of a capillary discharge waveguide using laser inverse bremsstrahlung heating. This allowed for the production of electron beams with quasimonoenergetic peaks up to 7.8 GeV, double the energy that was previously demonstrated. Charge was 5 pC at 7.8 GeV and up to 62 pC in 6 GeV peaks, and typical beam divergence was 0.2 mrad.

Suppression of Beam Hosing in Plasma Accelerators with Ion Motion

Mitigation of the beam hose instability in plasma-based accelerators is required for the realization of many applications, including plasma-based colliders. The hose instability is analyzed in the blowout regime including plasma ion motion, and ion motion is shown to suppress the hose instability by inducing a head-to-tail variation in the focusing force experienced by the beam. Hence, stable acceleration in plasma-based accelerators is possible, while, by use of proper bunch shaping, minimizing the energy spread and preserving the transverse beam emittance.

Measured Emittance Dependence on the Injection Method in Laser Plasma Accelerators

Single-shot, charge-dependent emittance measurements of electron beams generated by a laser plasma accelerator (LPA) reveal that shock-induced density down-ramp injection produces beams with normalized emittances a factor of 2 smaller than beams produced via ionization injection. Such a comparison is made possible by the tunable LPA setup, which allows electron beams with nearly identical central energy and peak spectral charge density to be produced using the two distinct injection mechanisms. Parametric measurements of this type are essential for the development of LPA-based applications which ultimately require high charge density and low emittance.

Multistage coupling of independent laser-plasma accelerators

Laser-plasma accelerators (LPAs) are capable of accelerating charged particles to very high energies in very compact structures. In theory, therefore, they offer advantages over conventional, large-scale particle accelerators. However, the energy gain in a single-stage LPA can be limited by laser diffraction, dephasing, electron-beam loading and laser-energy depletion. The problem of laser diffraction can be addressed by using laser-pulse guiding and preformed plasma waveguides to maintain the required laser intensity over distances of many Rayleigh lengths; dephasing can be mitigated by longitudinal tailoring of the plasma density; and beam loading can be controlled by proper shaping of the electron beam. To increase the beam energy further, it is necessary to tackle the problem of the depletion of laser energy, by sequencing the accelerator into stages, each powered by a separate laser pulse. Here, we present results from an experiment that demonstrates such staging. Two LPA stages were coupled over a short distance (as is needed to preserve the average acceleration gradient) by a plasma mirror. Stable electron beams from a first LPA were focused to a twenty-micrometre radius--by a discharge capillary-based active plasma lens--into a second LPA, such that the beams interacted with the wakefield excited by a separate laser. Staged acceleration by the wakefield of the second stage is detected via an energy gain of 100 megaelectronvolts for a subset of the electron beam. Changing the arrival time of the electron beam with respect to the second-stage laser pulse allowed us to reconstruct the temporal wakefield structure and to determine the plasma density. Our results indicate that the fundamental limitation to energy gain presented by laser depletion can be overcome by using staged acceleration, suggesting a way of reaching the electron energies required for collider applications.

Active Plasma Lensing for Relativistic Laser-Plasma-Accelerated Electron Beams

Compact, tunable, radially symmetric focusing of electrons is critical to laser-plasma accelerator (LPA) applications. Experiments are presented demonstrating the use of a discharge-capillary active plasma lens to focus 100-MeV-level LPA beams. The lens can provide tunable field gradients in excess of 3000 T/m, enabling cm-scale focal lengths for GeV-level beam energies and allowing LPA-based electron beams and light sources to maintain their compact footprint. For a range of lens strengths, excellent agreement with simulation was obtained.

Pulse evolution and plasma-wave phase velocity in channel-guided laser-plasma accelerators

The self-consistent laser evolution of an intense, short-pulse laser exciting a plasma wave and propagating in a preformed plasma channel is investigated, including the effects of pulse steepening and energy depletion. In the weakly relativistic laser intensity regime, analytical expressions for the laser energy depletion, pulse self-steepening rate, laser intensity centroid velocity, and phase velocity of the plasma wave are derived and validated numerically.

Essential and toxic elements in honeys from a region of central Italy

Levels of iron (Fe), manganese (Mn), chromium (Cr), copper (Cu), zinc (Zn), mercury (Hg), cadmium (Cd), and lead (Pb) in several types of honey produced in a region of Central Italy were determined by atomic absorption spectroscopy (AAS). The degree of humidity, sugar content, pH, free acidity, combined acidity (lactones), and total acidity were also measured. These elements were found to be present in honey in various proportions depending upon (1) the area foraged by bees, (2) flower type visited for collection of nectar, and (3) quality of water in the vicinity of the hive. Strong positive correlations occurred between Pb and Hg, Pb and Cd, Pb and Fe, Pb and Cr, Hg and Cd, and Hg and Fe. The honey products synthesized in Central Italy were of good quality, but not completely free of heavy metal contamination. Compared with established recommended daily intakes, heavy metals or trace element intoxication following honey consumption in Italy was found not to be a concern for human health.

Multi-GeV electron beams from capillary-discharge-guided subpetawatt laser pulses in the self-trapping regime

Multi-GeV electron beams with energy up to 4.2 GeV, 6% rms energy spread, 6 pC charge, and 0.3 mrad rms divergence have been produced from a 9-cm-long capillary discharge waveguide with a plasma density of ≈7×10¹⁷ cm⁻³, powered by laser pulses with peak power up to 0.3 PW. Preformed plasma waveguides allow the use of lower laser power compared to unguided plasma structures to achieve the same electron beam energy. A detailed comparison between experiment and simulation indicates the sensitivity in this regime of the guiding and acceleration in the plasma structure to input intensity, density, and near-field laser mode profile.

Psychopathology and eating disorders in patients with psoriasis

AIM

Psoriasis is a multifactorial chronic inflammatory skin disease that often occurs in patients who are overweight or obese. In literature the connections between obesity and eating disorders are well known, but few studies have investigated the link between eating disorders and psoriasis. We hypothesized that Eating Disorders (ED) can be considered a psychogenic cofactors, which contribute to the development of obesity and metabolic syndrome in psoriatic patients, who are frequently prone to psychiatric comorbidity.

METHODS

From January to April 2011 we enrolled 100 consecutive psoriatic outpatients and a control group of 100 selected non-psoriatic outpatients, matched by age, gender, and BMI to the study group. The assessment battery was composed by the Psoriasis Area Severity Index (PASI) score, the Eating Disorder Inventory (EDI) and the Symptom Checklist-90 Revised (SCL-90-R®).

RESULTS

Our data showed that most of EDI and SCL-90R subscales was mostly altered in psoriatic population compared to patients without psoriasis. Moreover, we noticed in patients with psoriasis an association between the progressive weight increase and an impairment on most of EDI subscales.

CONCLUSION

Psoriasis is associated with psychopathological traits, which are frequently found in EDs. Since obesity makes psoriasis less susceptible to therapy and weight loss improves drug response, dermatologists should be alert to suspect the presence of this condition.

Two-color laser-ionization injection

A method is proposed to generate femtosecond, ultralow emittance (∼10-8  m rad), electron beams in a laser-plasma accelerator using two lasers of different colors. A long-wavelength pump pulse, with a large ponderomotive force and small peak electric field, excites a wake without fully ionizing a high-Z gas. A short-wavelength injection pulse, with a small ponderomotive force and large peak electric field, copropagating and delayed with respect to the pump laser, ionizes a fraction of the remaining bound electrons at a trapping wake phase, generating an electron beam that is accelerated in the wake.

Low-emittance electron bunches from a laser-plasma accelerator measured using single-shot x-ray spectroscopy

X-ray spectroscopy is used to obtain single-shot information on electron beam emittance in a low-energy-spread 0.5 GeV-class laser-plasma accelerator. Measurements of betatron radiation from 2 to 20 keV used a CCD and single-photon counting techniques. By matching x-ray spectra to betatron radiation models, the electron bunch radius inside the plasma is estimated to be ~0.1 μm. Combining this with simultaneous electron spectra, normalized transverse emittance is estimated to be as low as 0.1 mm mrad, consistent with three-dimensional particle-in-cell simulations. Correlations of the bunch radius with electron beam parameters are presented.

Coupled beam hose and self-modulation instabilities in overdense plasma

Transverse stability of the drive beam is critical to plasma wakefield accelerators. A long, relativistic particle beam propagating in an overdense plasma is subject to beam envelope modulation and centroid displacement (hosing) instabilities. Coupled equations for the beam centroid and envelope are derived and solved. It is shown that the hosing growth rate is comparable to self-modulation, and coupling of the self-modulation enhances beam hosing and induces harmonic content. Large amounts of hosing significantly alters the structure of the plasma wakefields.

Long-range persistence of femtosecond modulations on laser-plasma-accelerated electron beams

Laser plasma accelerators have produced femtosecond electron bunches with a relative energy spread ranging from 100% to a few percent. Simulations indicate that the measured energy spread can be dominated by a correlated spread, with the slice spread significantly lower. Measurements of coherent optical transition radiation are presented for broad-energy-spread beams with laser-induced density and momentum modulations. The long-range (meter-scale) observation of coherent optical transition radiation indicates that the slice energy spread is below the percent level to preserve the modulations.

Growth and phase velocity of self-modulated beam-driven plasma waves

A long, relativistic particle beam propagating in an overdense plasma is subject to the self-modulation instability. This instability is analyzed and the growth rate is calculated, including the phase relation. The phase velocity of the wake is shown to be significantly less than the beam velocity. These results indicate that the energy gain of a plasma accelerator driven by a self-modulated beam will be severely limited by dephasing. In the long-beam, strongly coupled regime, dephasing is reached in a homogeneous plasma in less than four e foldings, independent of beam-plasma parameters.

Magnetically guided fast electrons in cylindrically compressed matter

Fast electrons produced by a 10 ps, 160 J laser pulse through laser-compressed plastic cylinders are studied experimentally and numerically in the context of fast ignition. K(α)-emission images reveal a collimated or scattered electron beam depending on the initial density and the compression timing. A numerical transport model shows that implosion-driven electrical resistivity gradients induce strong magnetic fields able to guide the electrons. The good agreement with measured beam sizes provides the first experimental evidence for fast-electron magnetic collimation in laser-compressed matter.

Nonlinear pulse propagation and phase velocity of laser-driven plasma waves

Laser evolution and plasma wave excitation by a relativistically intense short-pulse laser in underdense plasma are investigated in the broad pulse limit, including the effects of pulse steepening, frequency redshifting, and energy depletion. The nonlinear plasma wave phase velocity is shown to be significantly lower than the laser group velocity and further decreases as the pulse propagates owing to laser evolution. This lowers the thresholds for trapping and wave breaking and reduces the energy gain and efficiency of laser-plasma accelerators that use a uniform plasma profile.

Cohesive, multicomponent, dense powder flow characterization by NIR

Non-aerated powder flows are frequently encountered in downstream pharmaceutical processes. Such flows occur at the entrance of powder compression units, and their characteristics are of great interest because any powder agglomeration or segregation can be detrimental to the quality of the final solid oral dosage form. This work was aimed at developing a process analytical technology (PAT) method, based on near-infrared spectroscopy (NIR) for the in-line powder flow characterization of pharmaceutical formulations. An Ibuprofen drug formulation was selected for study. A bench-scale hopper system was assembled to monitor powder flow behaviour. An in-line commercial NIR Axsun spectrometer and probe were chosen to collect in-line spectral data on dense, multicomponent, non-aerated powder flow prior to compression. Spectra were collected on flowing mannitol and pharmaceutical product blends. A specially designed, non-contact sampling interface allowed the collection of representative process powder flow spectra without affecting blend uniformity. A partial least squares chemometric model was developed for laboratory-prepared samples, to quantitatively determine the flowing powder's active pharmaceutical ingredient (API) level. Static sample spectra and flowing pure mannitol spectra proved to have a high degree of reproducibility. The model's standard error of calibration was 2.95% of the API level with a R2 of 0.991. Flowing blend powder spectra and API estimates showed variations consistent with those seen in model samples. The average values for flowing pharmaceutical blends were close to the API concentration, indicating that the proposed procedure was statistically acceptable. The model is considered very promising, and some improvements would lead to its final acceptance at production scale as a PAT tool.

Applied nanotechnology for the management of breakthrough cancer pain

Pain, often considered the 5th vital sign, plays a significant role in the pathophysiology of cancer. Often addressed as an afterthought, untreated or under-treated cancer-related pain can have deleterious effects on a patient's physical and psychological well-being. Additionally, patients with breakthrough cancer pain tend to have more intense and more frequent background pain than patients without breakthrough pain. Currently, only oral transmucosal fentanyl citrate (OTFC) has reached the market for the treatment of cancer-related breakthrough pain. OTFC is an excellent first step in addressing the unmet need for symptomatic relief of breakthrough cancer pain; however, there is much room for improvement. Nanoscale science and engineering advancements have the long-term potential to bring revolutionary changes in society and across virtually all physical, biological and engineering disciplines, particularly medicine. Nanotechnology offers the potential to address multiple, major unmet problems in the diagnosis, treatment and symptom management of a large variety of diseases and conditions, including cancer. Nanotechnology can engender transformational progress in crucial aspects of the fight against cancer, spanning the continuum that ranges from prevention, to early detection, screening and monitoring, to innovative diagnostics and therapeutic modalities in the era of patient-centered, molecular medicine. Specifically, the authors will discuss their current research in the field of biomedical nanotechnology and its application to the management of breakthrough cancer pain.

Cutaneous bacterial colonization, modalities of chemotherapeutic infusion, and catheter-related bloodstream infection in totally implanted venous access devices

GOALS OF WORK

Prospective clinical study to evaluate patients suffering from solid tumor using a totally implanted venous access device (TIVAD) to determine: (1) if there is a relationship between cutaneous contamination at port insertion site and catheter-related bloodstream infection (CRBI); (2) development modalities of CRBI; (3) if there is a relationship between chemotherapy administration modalities by push/ bolus versus continuous infusion and CRBI.

PATIENTS AND METHODS

We studied 41 consecutive patients who needed a TIVAD positioned for chemotherapy administration by bolus/ push or continuous infusion. In every patient, we performed blood cultures from blood samples from port catheters and cutaneous cultures from cutaneous tampons of the skin surrounding the implant area on the first (T0) and eight day (T1) postoperatively, after 1 month (T2), and after 3 months (T3) from insertion.

MAIN RESULTS

The study was completed on 40 patients; in one case, the port was removed at T2 for septic complications. We obtained four positive blood cultures (two, 5%), two in the same patient, all caused by staphylococcus. Positive cutaneous tampons were 21 (13%) in 11 patients (27%); the four CRBI occurred in this group of patients with none in the remaining 30 patients (73%) for a total number of 120 tampons (p<0.01). In two cases, the same germ was isolated from both the skin and blood. None of the patients presented a local infection of the subcutaneous pocket. Positive cutaneous cultures decrease over time: T0-T2; 24-5%; T1-T3, 20-5% (p<0.04). There were no differences in CRBI incidence and positive cutaneous tampons between the two chemotherapy administration modalities.

CONCLUSIONS

Cutaneous microbial flora has a primary role in CRBI development within TIVADs; there is a relationship between cutaneous colonization and CRBI; colonization reaches its maximum during the first days after catheterization in which the use of the system is at high risk; colonization occurs both via extraluminal and endoluminal routes; there is no difference in CRBI incidence between bolus and continuous infusion administration.

Changes in plasma level of human leukocyte elastase during leukocytosis from physical effort

Physical exercise is known to induce immunological changes, mainly leukocytosis and neutrophil activation. However, it is not known to what extent the leukocytosis, observed after exertion, is associated with an increase in plasma neutrophil elastase, an early marker of inflammatory response and neutrophil degranulation. In the present study changes in circulating leukocyte and neutrophil counts and human neutrophil elastase plasma levels were evaluated in volley-ball players before and after 2 h and 12 h prolonged training, during a competition season. For comparison, the same parameters were evaluated in untrained subjects before and after a jogging session. Basal white blood cell WBC, polymorpho nuclear PMN, and human polymorpho nuclear-elastase PMN-ELA values were within the normal healthy reference range and no significant differences were found between the two groups studied. Venous blood samples of nine volley-ball players showed a statistically significant increase in blood WBCs after 2 h exercise. This effect was paralleled by a statistically significant increase in PMN-ELA concentration compared to the values observed in the same individuals at rest. The exercise did not significantly change the basal correlation parameters between PMN level and PMN-ELA concentration. More pronounced WBC, PMN, and PMN-ELA increases were observed in the seven inactive subjects after 2 h jogging. There was no linear correlation between increased PMN counts and increased PMN-ELA concentrations in untrained subjects after exercise. The results show that not only the leukocyte count but also PMN-ELA plasma levels can be higher after physical effort. This has a practical significance as regards differential diagnosis demonstrating that determination of these two laboratory parameters can give abnormally high values even in the absence of an existing inflammatory process. Besides, lack of correlation between PMN count and PMN-ELA plasma levels in the untrained group suggest a state in which activation of the neutrophils is not connected with their number in peripheral blood.

The contribution of general and specific motor inhibitory sets to the so-called auditory inhibition of return

The detection of sounds that come from a region of space recently exposed to acoustic stimulation is often slower than the detection of sounds coming from regions of space previously unexposed to acoustic stimulation. The relative increase in reaction time (RT) to targets in recently stimulated locations is generally termed "inhibition of return" (IOR). This term alludes to the possibility that spatial attention is biased against returning to recently visited locations, thus favoring the sampling of new sources of information. However, auditory IOR effects found in paradigms where subjects have to detect a first sound (cue) without making an overt response to it, and then respond as fast as possible to a second sound (target), may be due to a purely motor inhibition carried over from cue to target. Such motor inhibition has been shown to be maximal when cue and target belong to the same category, such as when they occupy the same spatial position. We have assessed the possible contribution of this motor inhibition to auditory IOR effects by having subjects respond to both cues and targets randomly presented in a right location and a left location. Reaction time to targets preceded by cues at the same location was longer than reaction times to targets preceded by cues at the opposite location (IOR effect). Compared to a condition in which subjects responded only to targets, the IOR effect was smaller, but still significant, in the double response condition, suggesting that such an effect depends on both motor inhibition and other factors, possibly related to covert spatial orienting and oculomotor control. A second experiment indicated that the IOR effect component independent of motor inhibition was slightly but significantly greater when space was relevant to the task because subjects had to report the positions of both cues and targets, compared to when space was irrelevant to the task because subjects were not required to report stimulus positions.

[Drug-induced taste disorders: analysis of the French Pharmacovigilance Database and literature review]

Taste disorders, generally poorly studied, have various causes. From 1985 to 1997, 305 observations of taste disorders imputed to drugs were notified to Regional Pharmacovigilance Centres. Patients were on average 54.4 years old and 58 per cent were women. Quantitative as well as qualitative disorders have been observed. Drugs mainly found were: angiotensin converting enzyme inhibitors, terbinafine, zopiclone, D-penicillamine, imidazole derivatives, quinolones, macrolides, carbimazole and calcium channel blockers. The outcome was favourable for 60.3 per cent of patients. The possible efficacy of zinc is discussed. It is generally considered that taste disorders are not a serious side-effect, but they can reduce the quality of life and lead to poor compliance with treatment.

Mirtazepine: heir apparent to amitriptyline?

"What's new in therapeutics?" will examine and evaluate drugs that may have a place in hospice, palliative, and long-term care. Mirtazepine will be examined and evaluated. Mirtazepine is a potential alternative anti-depressant with multiple additional benefits. It is an atypical anti-depressant, which has both noradrenergic and specific serotonergic receptor antagonism (NaSSa), and a unique pharmacological profile. Mirtazepine appears to be a "designer drug" for palliative medicine with a number of benefits, but cost may be a drawback.

Lack of changes in serum prolactin, FSH, TSH, and estradiol after melatonin treatment in doses that improve sleep and reduce benzodiazepine consumption in sleep-disturbed, middle-aged, and elderly patients

An open pilot study on the safety and efficacy of melatonin in the treatment of insomniac patients was conducted in 22 subjects (16 females), mean +/- S.D. age 60.1 +/- 9.5 years. All patients received 3 mg of gelatin melatonin capsules per os daily for 6 months, 30 min before expected sleep time. Twenty of 22 patients were on benzodiazepine treatment and they continued this treatment for part of or for the entire melatonin administration period. Serum concentrations of prolactin, follicle-stimulating hormone (FSH), thyroid-stimulating hormone (TSH), or estradiol were measured by radioimmunoassay (RIA) in morning samples at the beginning and after 6 months of melatonin administration, and standard clinical laboratory tests for blood components were performed. Urinary 6-sulphatoxymelatonin (aMT6s) excretion was measured by RIA before treatment. Serum concentrations of prolactin, FSH, TSH, or estradiol did not exhibit changes after 6 months of melatonin administration, nor were any indications of hematologic or blood biochemistry alteration found. Melatonin augmented significantly the quality and duration of sleep, and decreased sleep latency and the number of awakening episodes, as assessed from sleep logs filled by the patients (first 21 days) and from structured interviews performed by incumbent physicians (up to 6 months). Estimates of next-day function (i.e., alertness in the morning and during the day) also improved significantly during melatonin treatment. The observed effect lasted for the entire period examined (up to 6 months), with 22 out of 22 patients showing improved sleep at the end of treatment. The urinary excretion of aMT6s before starting administration of melatonin correlated negatively and significantly with age, but not with the intensity of sleep the disorder or the outcome of treatment. In 13 of 20 patients taking benzodiazepines together with melatonin, benzodiazepine use could be stopped, and in another four patients, benzodiazepine dose could be decreased to 25-66% of the initial dose. The results of this open, subacute administration trial indicate that melatonin is a safe and useful treatment for sleep disturbances in middle-aged or elderly patients, either by itself or together with benzodiazepines.