Dextromethorphan and memantine after ketamine analgesia: a randomized control trial

Purpose

Intravenous ketamine is often prescribed in severe neuropathic pain. Oral N-methyl-D-aspartate receptor (NMDAR) antagonists might prolong pain relief, reducing the frequency of ketamine infusions and hospital admissions. This clinical trial aimed at assessing whether oral dextromethorphan or memantine might prolong pain relief after intravenous ketamine.

Patients and methods

A multicenter randomized controlled clinical trial included 60 patients after ketamine infusion for refractory neuropathic pain. Dextromethorphan (90 mg/day), memantine (20 mg/day) or placebo was given for 12 weeks (n=20 each) after ketamine infusion. The primary endpoint was pain intensity at one month. Secondary endpoints included pain, sleep, anxiety, depression, cognitive function and quality of life evaluations up to 12 weeks.

Results

At 1 month, dextromethorphan maintained ketamine pain relief (Numeric Pain Scale: 4.01±1.87 to 4.05±2.61, p=0.53) and diminished pain paroxysms (p=0.03) while pain intensity increased significantly with memantine and placebo (p=0.04). At 3 months, pain remained lower than at inclusion (p=0.001) and was not significantly different in the three groups. Significant benefits were observed on cognitive-affective domains and quality of life for dextromethorphan and memantine (p<0.05).

Conclusions

Oral dextromethorphan given after ketamine infusion extends pain relief during one month and could help patients to better cope with pain. Future studies should include larger populations stratified on pharmacogenetics screening. Optimization of an oral drug that could extend ketamine antihyperalgesia, with fewer hospital admissions, remains a prime challenge in refractory neuropathic pain.

[Tako-Tsubo syndrome during normal human immunoglobolin perfusion]

This is a case of an 82 year old female patient with myasthenia gravis, who following treatment with Human Normal Immunoglobulin (Tegeline(®)), developed dyspnoea, chest pain without cardiac insufficiency, inverted T wave on ECG with slight increase in Troponine T 0.43ng/mL (<0.2ng/mL normal value in our hospital) and marked increase in Pro-BNP 4900 (Nl≤450pg/mL for an age greater than 65 years old). Her coronary angiogram showed hypokinesia of apical area but was otherwise normal. Also, MRI ruled out inflammatory and ischemic cardiac diseases. The most likely diagnosis for us was Tako-Tsubo syndrome in relation with injection of Human Normal Immunoglobulin (Tegeline(®)) according to the Mayo clinic criteria.

Does religiosity protect against cognitive and behavioral decline in Alzheimer's dementia?

BACKGROUND

several studies have shown that religiosity has beneficial effects on health, mortality and pathological conditions; little is known about religiosity in Alzheimer's disease and the progression of its cognitive, behavioral and functional symptoms. Our aim was to identify any relationship between religiosity and the progression of cognitive impairment and behavioral disorders in mild-moderate Alzheimer's disease, and any relationship between the patient's religiosity and the stress in caregivers.

MATERIALS AND METHODS

64 patients with Alzheimer's disease were analyzed at baseline and 12 months later using the Mini-Mental State Examination (MMSE), the Behavioral Religiosity Scale (BRS) and the Francis Short Scale (FSS). Caregivers were also questioned on the patient's functional abilities (ADL, IADL), the behavioral disturbances (NPI), and on their stress (NPI-D, CBI). Patients were divided into 2 groups according to BRS: a score of <24 meant no or low religiosity (LR), while a score of > or =24 meant moderate or high religiosity (HR).

FINDINGS

LR patients had worsened more markedly after 12 months in their total cognitive and behavioral test scores. Stress was also significantly higher in the caregivers of the LR group. Global BRS and FSS scores correlated significantly with variations after 1 year in the MMSE (r: 0.50), NPI (r:-0.51), NPI-D (r:-0.55) and CBI (r:-0.62). A low religiosity coincided with a higher risk of cognitive impairment, considered as a 3-point decrease in MMSE score (OR 6.7, CI: 1.8-24.7).

INTERPRETATION

higher levels of religiosity in Alzheimer's dementia seem to correlate with a slower cognitive and behavioral decline, with a corresponding significant reduction of the caregiver's burden.

Microbiological and chemical profile of Lebanese qishta (heat-coagulated milk)

Qishta is a popular Middle Eastern coagulated cream product, prepared using a traditional heating and skimming process. This study in Lebanon aimed to assess the microbiological and chemical profile of the product. Samples selected from 31 different manufacturers and outlets were analysed using standard methods. The plate counts for the various microorganisms were either of borderline acceptability or unacceptable for Escherichia coli, Salmonella spp. and Listeria monocytogenes (detected in 32%, 7% and 42% of the analysed samples respectively). Chemically, the mean moisture content [67.5 (SD 2.6) g/100 g] and pH (6.53) were relatively high. High counts of spoilage and pathogenic microorganisms and the nature of its chemical composition make qishta highly perishable.

A retrospective pilot study on the development of cognitive, behavioral and functional disorders in a sample of patients with early dementia of Alzheimer type

This pilot study retrospectively analyzes the evolution of cognitive-behavioral symptoms and functional autonomy in a sample of patients with early diagnosis of probable Alzheimer's disease (AD). One hundred patients with early mild cognitive impairment (MCI) were considered and submitted to a multidimensional evaluation: the 53% presented probable AD. These 53 subjects were evaluated for cognitive performance by using the mini mental examination (MMSE), behavioral functions by the neuropsychiatric inventory (NPI) and functional dependence by the activities of daily living (ADL) and the instrumental ADL (IADL) scales at basal time and after 6-12 months. Results were analyzed according to the duration of therapy with acetyl-cholinesterase inhibitors (ACHEI) and to the timing of the beginning with respect to the diagnosis. AD patients treated with ACHEI at the moment of the diagnosis, showed a statistically significant improvement in MMSE (2.7+/-1.5) after 6 months (p=0.012) which was maintained even after 12 months. Subjects beginning ACHEI at the visit of 6 months showed a statistically worsened MMSE, even after 6 months of therapy (-2.8+/-1.7, p=0.026). We conclude that the timing of administration of ACHEI therapy in mild AD is essential to obtain beneficial effects on cognitive decline.

Cardiac Troponin T (cTn T) and the Postmortem Diagnosis of Sudden Death

PURPOSE

To evaluate the effectiveness of the increase of postmortem cardiac troponin T (cTn T) in acute disease-related deaths.

METHODS

Peripheral venous blood was sampled from 39 autopsies performed. Thirty nonhemolyzed specimens were considered in the final analysis (n = 30).Only the calculation of the cTn T was performed using the Roche Diagnostics Elecsys 2010 Immunoassay System. The high limit and the cutoff are 25 ng/mL. Deaths were divided into 2 groups, according to sudden cardiac deaths (group 1, n = 15) and non-cardiac-related deaths without resuscitation (group 2, n = 15).

RESULTS

All the cases with visual myocardial infarction had elevated concentrations of cTn T. The difference of the postmortem cTn T concentrations between resuscitated and nonresuscitated is nonsignificant. In the non-cardiac-related deaths, the elevated concentrations of cTn T were only noted in all cases of electrocution.

CONCLUSION

In clinical practice, several biochemical markers are used for the diagnosis of myocardial infarction. Because of its extreme specificity for myocardial damage, cTn T and cardiac troponin I (cTn I) are frequently used. The results of these assays could then be used to facilitate selection for cases that may be released following histologic examinations.

Cavitary lung masses in SLE patients: an unusual manifestation of CMV infection

The typical radiographical findings of cytomegalovirus pneumonitis are bilateral interstitial infiltrates. In this study, the current authors describe two patients on corticosteroid treatment for systemic lupus erythematosus, complicated by histologically confirmed cytomegalovirus pneumonitis, presenting as cavitary masses. This rare presentation of cytomegalovirus pneumonitis broadens the differential diagnosis of cavitary lesions to include cytomegalovirus infection in immunocompromised individuals.

The risk of radiocontrast nephropathy in patients with cirrhosis

A retrospective case-control study was conducted to determine whether liver cirrhosis might be a risk factor for radiocontrast induced nephropathy as has been suggested. Data from 72 patients with cirrhosis and 72 patients without cirrhosis who all received 100-150 ml of low osmolality radiocontrast medium for abdominal or chest computerized tomography scan were reviewed. Blood urea nitrogen and creatinine were recorded before and 48-72 h after the administration of an intravenous radiocontrast agent. Acute renal failure developed in two patients with cirrhosis (2.8%) and one patient in the control group (1.4%). This difference was not significant. There was no significant change in blood urea nitrogen and creatinine in either group after radiocontrast injection. Both of the cirrhotic patients who developed radiocontrast induced nephropathy had received high-dose diuretics and were hypovolemic. We conclude that hepatic cirrhosis per se may not be a risk factor for radiocontrast-induced nephropathy.

Effects of age on validity of self-reported height, weight, and body mass index: findings from the Third National Health and Nutrition Examination Survey, 1988-1994

OBJECTIVE

To compare self-reported to measured heights and weights of adults examined in the Third National Health and Nutrition Examination Survey (NHANES III), and to determine to what extent body mass index (BMI) calculated from self-reported heights and weights affects estimates of overweight prevalence compared with BMI calculated from measured values.

DESIGN

A complex sample design was used in NHANES III to obtain a nationally representative sample of the US civilian, noninstitutionalized population. During household interviews, survey respondents were asked their height and weight. Trained health technicians subsequently measured height and weight using standardized procedures and equipment.

SUBJECTS

The analytical sample consisted of 7,772 men and 8,801 women 20 years old and older.

STATISTICAL ANALYSES PERFORMED

Only persons with measured and self-reported heights and weights were included in the analysis, and statistical sampling weights were applied. t Tests, Pearson product moment correlation coefficients, sensitivity, and specificity analyses were used to determine the validity of self-reported measurements and prevalence estimates of overweight, defined as BMI of 25 or greater.

RESULTS

Age is an important factor in classifying weight, height, BMI, and overweight from self-reports. Statistically significant differences were found for the mean error (measured-self-reported values) for height and BMI that were notably larger for older age groups. For example, the mean error for height ranged from 2.92 to 4.50 cm for women and from 3.06 to 4.29 cm for men, 70 years and older. Despite the high correlation between measured and self-reported data, the prevalence of overweight calculated from measured values was higher than that calculated from self-reported values among older adults. When calculated with self-reported height, BMI was one unit lower than when calculated from measured height for persons > or = 70 years. Specificity was high but sensitivity decreased with increasing age cohorts. Regression equations are provided to determine actual height from self-reported values for older adults. CONCLUSION/APPLICATIONS: Self-reported heights and weights can be used with younger adults, but they have limitations for older adults, ages > or = 60 years. In research studies and in clinical settings involving older adults, failure to measure height and weight can result in subsequent misclassification of overweight status. Therefore, registered dietitians are encouraged to obtained a measured weight and height using a calibrated scale and stadiometer.

Descriptive anthropometric reference data for older Americans

OBJECTIVE

To present selected anthropometric data derived from adults aged 60 years and older examined in the third National Health and Nutrition Examination Survey (NHANES III).

DESIGN

NHANES III used a complex, stratified, multistage, probability cluster sample design to obtain a nationally representative sample of the US civilian, noninstitutionalized population. Persons aged 60 years and older, Mexican-Americans, and African-Americans were oversampled to produce more reliable estimates for these groups. Trained technicians measured height, weight, skinfold thickness, and circumferences using standardized procedures.

SUBJECTS

A total of 5,700 persons aged 60 years and older, and 1,861 persons aged 50 to 59 years.

STATISTICAL ANALYSES PERFORMED

Mean and selected percentiles for body weight, body mass index, triceps skinfold thickness, mid upper arm circumference, and arm muscle circumference were calculated by gender, race/ethnicity, and 3 age categories. Weight (lb) per height (in) tables were generated for men and women by age group.

RESULTS

Mean body weight was lowest for persons aged 80 years and older. A decline in body mass index occurred that paralleled the direction and magnitude of the progressive decrease observed in weight. Muscle loss with increasing age, as indicated by arm muscle circumference, appeared to be greater among men than women.

APPLICATIONS/CONCLUSIONS

In addition to being relatively simple, quick, and inexpensive, anthropometry is the most reliable and specific indicator of malnutrition in the older adult population. The cross-sectional reference data provided can be used by dietitians to interpret anthropometric measurements of persons aged 60 years and older.

HIV infection among women undergoing abortion in Montreal

OBJECTIVE

To determine the seroprevalence and correlates of HIV infection in a subpopulation of women of childbearing age in Montreal.

DESIGN

Anonymous unlinked seroprevalence study.

SETTING

Pregnancy termination unit in a teaching hospital in Montreal.

PARTICIPANTS

Women presenting for abortion from July 1989 to June 1993 who resided in Quebec and were not known to have HIV infection; 12,017 (99.6%) of 12,068 eligible women were included in the study.

INTERVENTION

HIV antibody testing of serum left over from samples obtained for routine Rh typing; the same algorithm as for serodiagnostic testing, namely enzyme immunoassay (EIA) followed by confirmatory testing of repeatedly EIA-reactive samples, was used.

OUTCOME MEASURES

HIV serostatus by age, marital status, region of residence (metropolitan Montreal versus other), country of birth and number of living children.

RESULTS

Most (84.7%) of the subjects resided in metropolitan Montreal. The median age was 27.0 (range 13 to 50) years. The serum samples of 22 women were confirmed to be HIV positive, for an overall seroprevalence rate of 1.8 per 1000 (95% confidence interval 1.1 to 2.8). The seroprevalence rate did not vary significantly by age, marital status, region of residence or study year. However, it was strongly correlated with country of birth: Canada 0.16, Haiti 23.5, HIV-endemic countries other than Haiti 5.3 and non-HIV-endemic countries other than Canada 0.0 per 1000. The seroprevalence rate among women born in Haiti was 147 times higher than that among women born in Canada (p < 0.0001). Of the women born in Haiti the rate was 3.0 times greater among those who immigrated to Canada in 1985 or later than among those who immigrated earlier (p = 0.047).

CONCLUSIONS

The results of this study indicate that the HIV seroprevalence rate among women in Montreal is strongly associated with country of birth, women born in HIV-endemic countries, especially Haiti, having the highest rate. These results will help in the development of policies regarding HIV antibody testing and prevention of HIV transmission in Quebec.