A 6-month, Randomized, Placebo-controlled, Double Blind Trial of Ziprasidone Plus a Mood Stabilizer in Subjects With Bipolar I Disorder

Background:

The objective of this study was to evaluate the efficacy and safety of ziprasidone adjunctive to a mood stabilizer for the maintenance treatment of bipolar mania.

Methods:

Male and female subjects with bipolar I disorder with MRS 3 14 were enrolled. Subjects achieving ≥ 8 consecutive weeks of stability with open-label ziprasidone (80-160 mg/d) and lithium or divalproex were randomized into the 6-month double-blind maintenance period, to ziprasidone + mood stabilizer or placebo + mood stabilizer. The primary and key secondary end points were the time to intervention for a mood episode, and time to discontinuation for any reason, respectively. Inferential analysis was performed using a Kaplan-Meier product-limit estimator (Log-rank test).

Results:

127 and 112 subjects were randomized to and treated in the ziprasidone and placebo groups, respectively. The time to intervention for a mood episode was significantly different, favoring ziprasidone (p = 0.0104). 19.7% and 32.4% of ziprasidone and placebo subjects, respectively, required intervention for a mood episode. Time to discontinuation for any reason was significantly different (p = 0.0047), favoring ziprasidone. Among treatment-emergent adverse events occurring in the double-blind period, the only event occurring more frequently in the ziprasidone group than in the placebo group (≥ 5%) was tremor (6.3% vs 3.6%, respectively).

Conclusions:

These results demonstrate that ziprasidone is an effective, safe, and well-tolerated adjunctive treatment with a mood stabilizer for long-term maintenance treatment of bipolar mania.

Treatment pathways for bipolar disorder in the USA and Europe: convergence or divergence?

Mood stabilising therapy is the cornerstone of treatment for bipolar disorder, a disease that is commonly associated with disabling psychosocial morbidity [37,11]. A variety of drugs have been approved for use in bipolar disorder, thus providing a wide array of options for clinicians when deciding on a course of treatment [28]. In order to assist clinical decision-making, facilitate optimal quality of care and reduce unnecessary variation in clinical practice, several clinical practice guidelines and treatment algorithms have been developed [4,19,20,21]. As well as similarities, there are some differences between guidelines developed from an American perspective and those developed from a European perspective [4,19], and there is a pervasive view in the clinical community that treatment of patients with bipolar disorder differs substantially between the United States (US) and Europe. This article discusses what is known about the similarities and differences of treatment practices for bipolar disorder between the US and Europe.

The relationship between attention deficit hyperactivity disorder, bipolarity and mixed features in major depressive patients: Evidence from the BRIDGE-II-Mix Study

OBJECTIVE

This study primarily focused on the relationship between comorbid attention deficit-hyperactivity disorder (ADHD), mixed features and bipolarity in major depressive patients.

METHODS

The sample comprised 2777 patients with Major Depressive Episode (MDE) enrolled in a multicentre, multinational study originally designed to assess different definitions of mixed depression. Socio-demographic, familial and clinical characteristics were compared in patients with (ADHD + ) and without (ADHD-) comorbid ADHD.

RESULTS

Sixty-one patients (2.2%) met criteria for ADHD. ADHD was associated with a higher number of (hypo)manic symptoms during depression. Mixed depression was more represented in ADHD + patients than in ADHD- using both DSM-5 and experimental criteria. Differences were maintained after removing overlapping symptoms between (hypo)mania and ADHD. ADHD in MDE was also associated with a variety of clinical and course features such as onset before the age of 20, first-degree family history of (hypo)mania, past history of antidepressant-induced (hypo)manic switches, higher number of depressive and affective episodes, atypical depressive features, higher rates of bipolarity specifier, psychiatric comorbidities with eating, anxiety and borderline personality disorders.

LIMITATIONS

The study was primarily designed to address mixed features in ADHD, with slightly reduced sensitivity to the diagnosis of ADHD. Other possible diagnostic biases due to heterogeneity of participating clinicians.

CONCLUSIONS

In a sample of major depressive patients, the comorbid diagnosis of current ADHD is associated with bipolar diathesis, mixed features, multiple psychiatric comorbidity and a more unstable course. Further prospective studies are necessary to confirm the possible mediating role of temperamental mood instability and emotional dysregulation in such a complex clinical presentation.

Assessing the Accuracy of Self-Reported Height and Weight in an Elective Surgical Population in a Melbourne Metropolitan Hospital

A Health Questionnaire serves as a screening form as part of our Hospital Preadmission process and is completed by all patients scheduled for elective surgery. We reviewed the completed Health Questionaires of 444 patients. Completion of the Health Questionnaire requires patients to record their height and weight. At the time of admission their actual height and weight was measured and recorded by nursing staff as part of the preoperative assessment. We compared their estimated body mass index (BMI) from self-reported height and weight, with their actual BMI calculated from height and weight measured upon admission. The measured BMI accorded well with that calculated from reported values and showed no systematic over- or under-reporting. Of 70 patients with a BMI greater than 35, only ten estimated their BMI less than 35 and only five of these had more than a two unit difference. Perioperative patients appear to be more accurate at providing height and weight than previously analysed non-patient groups. However there is not complete accuracy and some patients still provide unreliable information. Whether or not individual practitioners utilize BMI from self-reported height and weight will depend on the accuracy that they require for their purposes. Of note there was greater accuracy in prediction of height and weight than in the derived variable of BMI due to the calculations required.

The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Acute and long-term treatment of mixed states in bipolar disorder

OBJECTIVES

Although clinically highly relevant, the recognition and treatment of bipolar mixed states has played only an underpart in recent guidelines. This WFSBP guideline has been developed to supply a systematic overview of all scientific evidence pertaining to the acute and long-term treatment of bipolar mixed states in adults.

METHODS

Material used for these guidelines is based on a systematic literature search using various data bases. Their scientific rigour was categorised into six levels of evidence (A-F), and different grades of recommendation to ensure practicability were assigned. We examined data pertaining to the acute treatment of manic and depressive symptoms in bipolar mixed patients, as well as data pertaining to the prevention of mixed recurrences after an index episode of any type, or recurrence of any type after a mixed index episode.

RESULTS

Manic symptoms in bipolar mixed states appeared responsive to treatment with several atypical antipsychotics, the best evidence resting with olanzapine. For depressive symptoms, addition of ziprasidone to treatment as usual may be beneficial; however, the evidence base is much more limited than for the treatment of manic symptoms. Besides olanzapine and quetiapine, valproate and lithium should also be considered for recurrence prevention.

LIMITATIONS

The concept of mixed states changed over time, and recently became much more comprehensive with the release of DSM-5. As a consequence, studies in bipolar mixed patients targeted slightly different bipolar subpopulations. In addition, trial designs in acute and maintenance treatment also advanced in recent years in response to regulatory demands.

CONCLUSIONS

Current treatment recommendations are still based on limited evidence, and there is a clear demand for confirmative studies adopting the DSM-5 specifier with mixed features concept.

Poor quality of life and functioning in bipolar disorder

Background

This study explores the association of demographic and clinical features with quality of life and functioning in individuals with bipolar disorder.

Methods

Adult participants (N = 482) with bipolar I or II disorder were enrolled in a comparative effectiveness study across eleven study sites and completed baseline measures of medical and psychiatric history, current mood, quality of life, and functioning. Participants with at least mildly depressive or manic/hypomanic symptomatic severity were randomized to receive lithium or quetiapine in addition to adjunctive personalized treatment for 6 months.

Results

Participants with more severe depressive and irritability symptoms had lower quality of life and higher functional impairment. All psychiatric comorbid conditions except substance use disorder were associated with worse quality of life. On average, females had lower quality of life than males. Patients who were married, living as married, divorced, or separated had worse functional impairment compared with patients who were single or never married. A composite score of social disadvantage was associated with worse functioning and marginally associated with worse quality of life. Symptom severity did not moderate the effect of social disadvantage on quality of life or functioning.

Conclusions

Our findings highlight that depression, irritability, and psychiatric comorbid conditions negatively impact quality of life and functioning in bipolar disorder. The study suggests that individuals with social disadvantage are at risk for functional impairment.

Trial Registration This study is registered with ClinicalTrials.gov. Identification number: NCT01331304

The bipolar-borderline personality disorders connection in major depressive patients

OBJECTIVE

The study focuses on the controversial relationship between borderline personality disorder (BPD) and bipolar disorder (BD), defined according to different criteria set, in a world-wide sample of patients with a current major depressive episode (MDE).

METHOD

A total of 5635 patients with an MDE were enrolled in a multinational study, designed to assess varying definition of hypo/mania and familial and clinical variables associated with bipolarity. Patients with (BPD+) and without (BPD-)comorbid BPD were compared on sociodemographic, familial and clinical characteristics.

RESULTS

Five hundred and thirty-two patients (9.3%) met criteria for BPD. A diagnosis of BD was more frequent in BPD+ than in BPD- using either DSM-IVTR-modified criteria or the bipolar specifier. BPD+ were younger than BPD- depressives with regard to age and age at onset. They also showed more hypomania/mania in first-degree relatives in comparison to BPD- as well as more psychiatric comorbidity, psychotic symptoms, mixed states, atypical features, seasonality of mood episodes, suicide attempts, prior mood episodes and antidepressants-induced hypo/manic switches.

CONCLUSION

In our sample, selected on the basis of the presence of a mood disorder, the BD-BPD connection is confirmed by the high prevalence of bipolarity in depressive patients with BPD and by the significant association with familial and clinical features classically considered as external validators of bipolarity.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: update 2012 on the long-term treatment of bipolar disorder

OBJECTIVES

These guidelines are based on a first edition that was published in 2004, and have been edited and updated with the available scientific evidence up to October 2012. Their purpose is to supply a systematic overview of all scientific evidence pertaining to the long-term treatment of bipolar disorder in adults.

METHODS

Material used for these guidelines are based on a systematic literature search using various data bases. Their scientific rigor was categorised into six levels of evidence (A-F) and different grades of recommendation to ensure practicability were assigned.

RESULTS

Maintenance trial designs are complex and changed fundamentally over time; thus, it is not possible to give an overall recommendation for long-term treatment. Different scenarios have to be examined separately: Prevention of mania, depression, or an episode of any polarity, both in acute responders and in patients treated de novo. Treatment might differ in Bipolar II patients or Rapid cyclers, as well as in special subpopulations. We identified several medications preventive against new manic episodes, whereas the current state of research into the prevention of new depressive episodes is less satisfactory. Lithium continues to be the substance with the broadest base of evidence across treatment scenarios.

CONCLUSIONS

Although major advances have been made since the first edition of this guideline in 2004, there are still areas of uncertainty, especially the prevention of depressive episodes and optimal long-term treatment of Bipolar II patients.

Is comorbid borderline personality disorder in patients with major depressive episode and bipolarity a developmental subtype? Findings from the international BRIDGE study

BACKGROUND

The nature of the relationship between bipolar disorder (BD) and borderline personality disorder (BPD) is controversial. The aim of this study was to characterize the clinical profile of patients with BD and comorbid BPD in a world-wide sample selected during a major depressive episode (MDE).

METHODS

From a general sample of 5635 in and out-patients with an MDE, who were enrolled in the multicenter, multinational, transcultural BRIDGE study, we identified 2658 subjects who met bipolarity specifier criteria. Bipolar specifier patients with (BPD+) and without (BPD-) comorbid BPD were compared on diagnostic, socio-demographic, familial and clinical characteristics.

RESULTS

386 patients (14.5%) met criteria for BPD. A diagnosis of BD according to DSM-IV criteria was significantly more frequent in the BPD- than in BPD+, while similar rates in the two groups occurred using DSM-IV-Modified criteria. A subset of the BD criteria with an atypical connotation, such as irritability, mood instability and reactivity to drugs were significantly associated withthe presence of BPD. BPD+ patients were significantly younger than BPD- bipolar patients for age, age at onset of first psychiatric symptoms and age at first diagnosis of depression. They also reported significantly more comorbid Alcohol and Substance abuse, Anxiety disorders, Eating Disorder and Attention Deficit Hyperactivity Disorder. In comparison with BPD-, BPD+ patients showed significantly more psychotic symptoms, history of suicide attempts, mixed states, mood reactivity, atypical features, seasonality of mood episodes, antidepressants induced mood lability and irritability, and resistance to antidepressant treatments.

LIMITATIONS

Centers were selected for their strong mood disorder clinical programs, recall bias is possible with a cross-sectional design, and participating psychiatrists received limited training.

CONCLUSIONS

We confirm in a large sample of BD patients with MDE the high prevalence of patients who meet DSM-IV criteria for BPD. Further prospective researches should clarify whether the mood reactivity and instability captured by BPD DSM-IV criteria are distinguishable from the subjective mood of an instable, dysphoric, irritable manic/hypomanic/mixed state or simply represent a phenotypic variant of BD, related to developmental factors.

Comparison of the Bonfils and Levitan optical stylets for tracheal intubation: a clinical study

The Bonfils and Levitan FPS scopes are rigid fibreoptic stylets that may assist routine or difficult intubation. This study compared the effectiveness of each in patients with predicted normal airways when used by specialist anaesthetists with no prior experience using optical stylets. Twelve anaesthetists and 324 elective surgical patients participated. Six anaesthetists were randomised to first intubate 20 patients with the Levitan scope (Phase 1) followed by a further seven patients with the Bonfils scope (Phase 2). The other six participating anaesthetists undertook their first 20 intubations with the Bonfils (Phase 1), followed by seven intubations with the Levitan (Phase 2). Outcomes recorded were success rate, total time to intubation, number of attempts, ease of intubation score and incidence of complications. Overall failure rates were similar for the two scopes with 5.6% of patients not intubated after three attempts. Median total times to intubation were similar for the Levitan (44 seconds) and Bonfils (36 seconds) (P = 0.11). Participants using the Bonfils in Phase 1 had significantly higher chance of success on first attempt (73%) compared to Levitan users during Phase 1 (57%) (P = 0.008). These differences were not significant in the second phase and ease of intubation scores were similar for both scopes (P = 0.9). This study showed the two scopes were comparable but the high failure rate amongst novice users demonstrated the importance of familiarity and skill development prior to their introduction to a difficult airway cart.

Early symptom change and prediction of subsequent remission with olanzapine augmentation in divalproex-resistant bipolar mixed episodes

Potential predictors of remission in mixed bipolar I disorder were identified using early Clinical Global Impression-Severity (CGI-S) improvement criteria in divalproex-resistant patients randomized to olanzapine augmentation (olanzapine + divalproex; N = 101) in a 6-week, double-blind, placebo-controlled trial. In a post-hoc analysis, receiver operating characteristics of 1-point decreases in the CGI-S total score after 2, 4, 7, and 14 days were examined as predictors of endpoint (Week 6 or last observation) remission of depression and/or mania as defined by 21-item Hamilton Depression Rating Scale (HDRS-21) and Young Mania Rating Scale (YMRS) total score ≤8. Based on a 1-point improvement in CGI-S as a predictor of remission, all odds ratios (ORs) and 95% confidence intervals (CIs) were statistically significant for depression or mania remission criteria. ORs for mixed symptom remission with a decrease ≥1 in CGI-S scores at Day 2 for olanzapine augmentation were (6.727; CI: 2.382, 18.997; p < .001) with negative predictive value = 89.5% and positive predictive value = 44.2%. Changes in HDRS-21 and YMRS individual item scores after 2 days of augmentation as predictors of endpoint remission identified that decreases in HDRS-21 symptom item scores (early, middle, and/or late insomnia; paranoid; agitation; and somatic/gastrointestinal) predicted depressive symptom remission at endpoint, and decreases in YMRS item scores (language-thought disorder and irritability) were associated with manic symptom remission at endpoint. Because remission with augmentation therapy may occur in as few as one in ten individuals who lack very early symptom reduction, lack of early improvement may indicate a need to expediently reassess treatment strategy.

The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders: Update 2010 on the treatment of acute bipolar depression

OBJECTIVES

These guidelines are based on a first edition that was published in 2002, and have been edited and updated with the available scientific evidence until September 2009. Their purpose is to supply a systematic overview of all scientific evidence pertaining to the treatment of acute bipolar depression in adults.

METHODS

The data used for these guidelines have been extracted from a MEDLINE and EMBASE search, from the clinical trial database clinicaltrials.gov, from recent proceedings of key conferences, and from various national and international treatment guidelines. Their scientific rigor was categorised into six levels of evidence (A-F). As these guidelines are intended for clinical use, the scientific evidence was finally assigned different grades of recommendation to ensure practicability.

RESULTS

We identified 10 pharmacological monotherapies or combination treatments with at least limited positive evidence for efficacy in bipolar depression, several of them still experimental and backed up only by a single study. Only one medication was considered to be sufficiently studied to merit full positive evidence.

CONCLUSIONS

Although major advances have been made since the first edition of this guideline in 2002, there are many areas which still need more intense research to optimize treatment. The majority of treatment recommendations is still based on limited data and leaves considerable areas of uncertainty.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders: update 2009 on the treatment of acute mania

These updated guidelines are based on a first edition that was published in 2003, and have been edited and updated with the available scientific evidence until end of 2008. Their purpose is to supply a systematic overview of all scientific evidence pertaining to the treatment of acute mania in adults. The data used for these guidelines have been extracted from a MEDLINE and EMBASE search, from the clinical trial database clinicaltrials.gov, from recent proceedings of key conferences, and from various national and international treatment guidelines. Their scientific rigor was categorised into six levels of evidence (A-F). As these guidelines are intended for clinical use, the scientific evidence was finally asigned different grades of recommendation to ensure practicability.

Olanzapine versus divalproex versus placebo in the treatment of mild to moderate mania: a randomized, 12-week, double-blind study

OBJECTIVE

To evaluate the efficacy and safety of olanzapine, divalproex, and placebo in a randomized, double-blind trial in mild to moderate mania (DSM-IV-TR criteria).

METHOD

The study was conducted from October 2004 to December 2006. A total of 521 patients from private practices, hospitals, and university clinics were randomly assigned to olanzapine (5-20 mg/day), divalproex (500-2500 mg/day), or placebo for 3 weeks; those completing continued with a 9-week double-blind extension. Efficacy (mean change in Young Mania Rating Scale [YMRS] total score was the primary outcome) and safety were assessed.

RESULTS

After 3 weeks of treatment, olanzapine-treated (N = 215) and placebo-treated (N = 105) patients significantly differed in YMRS baseline-to-endpoint total score change (p = .034; least squares [LS] mean: -9.4 and -7.4, respectively). Such changes were not significantly different between olanzapine vs. divalproex (N = 201) or divalproex vs. placebo. After 12 weeks of treatment, olanzapine- and divalproex-treated patients significantly differed in YMRS baseline-to-endpoint changes (p = .004; LS mean: -13.3 and -10.7, respectively). Of observed cases, 35.4% (35/99; 3 weeks) to 57.1% (28/49; 12 weeks) had valproate plasma concentrations lower than the recommended valproate therapeutic range, but these patients' YMRS scores were lower than those of patients with valproate concentrations above/within range. Compared with divalproex, after 12 weeks, olanzapine-treated patients had significant increases in weight (p < .001) and in glucose (p < .001), triglyceride (p = .003), cholesterol (p = .024), uric acid (p = .027), and prolactin (p < .001) levels. Divalproex-treated patients had significant decreases in leukocytes (p = .044) and platelets (p < .001) compared with olanzapine after 12 weeks of treatment. The incidence of potentially clinically significant weight gain (>/= 7% from baseline) was higher with olanzapine than with divalproex (3-week: p = .064, 6.4% vs. 2.7%; 12-week: p = .002, 18.8% vs. 8.5%; respectively).

CONCLUSION

Olanzapine was significantly more efficacious than placebo but not divalproex at 3 weeks and significantly more efficacious than divalproex at 12 weeks. Olanzapine-treated patients had significantly greater increases in weight and in glucose, cholesterol, triglyceride, uric acid, and prolactin levels than divalproex-treated patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00094549.

A 12-week, open, randomized trial comparing sodium valproate to lithium in patients with bipolar I disorder suffering from a manic episode

On the basis of 3-week studies, lithium and valproate are both recommended for first-line treatment of acute mania. It is, however, also important to demonstrate that antimanic efficacy can be maintained. This study has been designed to compare the efficacy and tolerability of valproate and lithium over 12 weeks in the treatment of acute mania in patients with type I bipolar disorder. Three hundred patients with bipolar I disorder presenting with acute mania were randomized to open treatment with lithium (starting dose: 400 mg/day) or valproate (starting dose: 20 mg/kg/day) for 12 weeks. The primary efficacy criterion was remission (YMRS score <or=12 at study end and a reduction of >or=2 on the CGI-BP severity scale). Remission rates were 65.5% (lithium group) and 72.3% (valproate group). Noninferiority of valproate with respect to lithium was demonstrated [between-group difference: 6.78% (95% confidence intervals: -3.80 to 17.36%)]. Remission rates assessed by the secondary mixed model repeated measures analysis were significantly greater with valproate than with lithium. Adverse events were reported in 44% of patients in both groups. Valproate and lithium showed comparable efficacy and tolerability in the treatment of acute mania over 12 weeks.

Effect of comorbid anxiety on treatment response in bipolar depression

BACKGROUND

This secondary analysis from a randomized double-blind study of acute bipolar depression compared olanzapine monotherapy, olanzapine-fluoxetine combination (OFC) and placebo in patients with or without comorbid anxiety.

METHODS

Patients with bipolar disorder and a current depressive episode received olanzapine (5-20 mg/day), OFC (6/25, 6/50, or 12/50 mg/day), or placebo in an 8-week trial. Two populations were defined: comorbid (Hamilton Anxiety Rating Scale, HAM-A > or =18) or non-comorbid (HAM-A <18) anxiety. Changes in Montgomery-Asberg Depression Rating Scale (MADRS) and HAM-A total scores, and rates of response (> or =50% decrease from baseline to endpoint) and remission (MADRS < or =12 or HAM-A < or =7) were analyzed.

RESULTS

Baseline MADRS and YMRS scores were significantly higher in patients with comorbid anxiety relative to those without. Patients without comorbid anxiety were more likely to achieve MADRS response and remission than those with comorbid anxiety (relative risk, RR: 1.21 and 1.29, respectively). Patients with comorbid anxiety had greater rates of response and remission with olanzapine and OFC relative to placebo (response RR:1.45 and 2.14; remission RR:1.96 and 2.32, respectively). Response and remission rates on the HAM-A scale were greater for OFC relative to placebo (RR: 2.00 and 3.20). Weight gain was greater for olanzapine (2.59+/-3.24 kg) and OFC (2.79+/-3.23 kg) relative to placebo, as were baseline to endpoint changes in cholesterol levels (6+/-31 and 10+/-67 mg/dL, respectively).

CONCLUSIONS

Comorbid anxiety symptoms in patients with bipolar depression have a negative impact on treatment outcome. Olanzapine and, to a greater extent, olanzapine-fluoxetine combination were effective in reducing both depressive and anxiety symptoms in these patients. The significantly greater changes in weight, glucose and cholesterol parameters observed in the olanzapine and olanzapine-fluoxetine combination groups should be entered into the risk-benefit assessment in determining appropriate treatment options for these patients.

Bipolar disorders: treatment options and patient satisfaction

Functional recovery, the goal of treatment, has long been overlooked in the assessment of effectiveness of pharmacological treatments. However, with the recent shift in paradigm, from syndromal-symptomatic recovery to functional recovery, there appears to be a new interest in the definition and evaluation of functional recovery. Since functional recovery lags symptomatic recovery, sometimes by months or years, the attainment of functional recovery will be determined by both efficacy and long-term compliance. Quetiapine, due to its efficacy in both mania and depression, and effect on cognition may lead to improved functioning in patients with bipolar disorder.

Effects of lamotrigine and lithium on body weight during maintenance treatment of bipolar I disorder

OBJECTIVE

The effect of lamotrigine maintenance therapy on body weight was assessed retrospectively in analyses of data from two double-blind, placebo- and lithium-controlled, 18-month studies in patients with bipolar I disorder (n = 227 for lamotrigine, 190 for placebo, 166 for lithium).

METHODS

Endpoints included mean change in weight, the percentage of patients with > or = 7% change (increase, decrease, fluctuation) in weight, and the percentage of patients with weight-related adverse events during double-blind treatment.

RESULTS

Mean weight remained stable during maintenance therapy with lamotrigine. In a mixed-model repeated-measures analysis, mean changes in weight (kg) at week 52 were -1.2 with lamotrigine, +0.2 with placebo, and +2.2 with lithium [estimated difference (95% CI) lamotrigine minus placebo = -1.3 (-3.6, 0.9), p = 0.237; lithium minus placebo = +2.0 (-0.3, 4.4), p = 0.094; lithium minus lamotrigine = +3.4 (1.4, 5.4), p < 0.001]. Analyses were truncated at week 52 because of the high incidence of missing data at later time points. The percentages of patients with a >/=7% weight gain, during randomized treatment, were 10.9%, 7.6% and 11.8% for the lamotrigine, placebo, and lithium groups, respectively. The percentages of patients with a > or = 7% weight loss, during randomized treatment, were 12.1%, 11.5%, and 5.1% for the lamotrigine, placebo, and lithium groups, respectively. The percentage of patients with a > or = 7% weight loss did not significantly differ between lamotrigine and placebo but was significantly higher with lamotrigine than lithium. The incidences of > or = 7% weight changes and of weight changes reported as adverse events were comparable between active treatments and placebo.

CONCLUSION

Lamotrigine was associated with stable body weight during 1 year of treatment and was comparable to placebo in mean weight change, incidence of clinically significant weight change, and incidence of weight changes reported as adverse events in patients with bipolar disorder. Lithium was associated with weight gain, but the magnitude of lithium-associated weight gain was lower in the current analysis than in previous studies.

Association of psychosis with suicidality in pediatric bipolar I, II and bipolar NOS patients

BACKGROUND

Psychosis in pediatric mood disorder patients may be related to suicidal ideation. Bipolar (BP) adolescents are at high risk of completed suicide. We examined whether pediatric BP patients with psychosis have a higher prevalence of suicidality than non-psychotic BP patients. Based on previous findings in adult BP patients, we predicted that pediatric BP patients with psychotic symptoms would have higher prevalence of suicidality, higher occurrence of lifetime psychiatric hospitalizations and worse current Global Assessment of Functioning Scale (GAF) scores compared to non-psychotic BP patients.

METHODS

We studied 43 BP children and adolescents (mean age +/- S.D = 11.2 +/- 2.8 y, range = 8-17) who did (n = 17) or did not have (n = 26) a lifetime history of psychotic symptoms. Indicators of suicidality (thoughts of death and suicidal ideation, plans, and attempts), psychiatric diagnoses, psychotic symptoms, psychiatric hospitalizations and GAF scores were assessed with the K-SADS-PL interview.

LIMITATIONS

Small sample size, cross-sectional study and exclusion of substance abuse comorbidity.

RESULTS

Pediatric BP patients with a lifetime history of psychotic symptoms compared to BP patients without psychosis were more likely to have thoughts of death (100% versus 69.2%, p = 0.01), suicidal ideation (94.1% versus 42.3%, p = 0.001) and suicidal plans (64.7% versus 15.4%, p = 0.002). Occurrence of psychiatric hospitalization was higher in psychotic BP patients compared to non-psychotic BP patients (82.4% versus 46.2%, p = 0.018).

CONCLUSIONS

Psychotic symptoms in pediatric BP patients are associated with suicidal ideation and plans, and psychiatric hospitalizations. Psychotic symptoms are a risk factor for suicidality amongst pediatric BP patients.

Sources of declarative memory impairment in bipolar disorder: mnemonic processes and clinical features

BACKGROUND

There is mounting evidence that declarative memory processes are impaired in patients with bipolar disorder. However, predictors of the observed impairment are not well understood. This study seeks to: (i) better characterize the nature of declarative memory impairment in bipolar disorder, and (ii) determine the relationship between clinical variables and memory function in bipolar disorder.

METHODS

49 adult patients with bipolar disorder in varying mood states and 38 demographically matched healthy participants completed a comprehensive neurocognitive battery assessing general cognitive functioning, processing speed, and declarative memory. The California verbal learning test was used to characterize learning and memory functions.

RESULTS

Although patients with bipolar disorder utilized a similar semantic clustering strategy to healthy controls, they recalled and recognized significantly fewer words than controls, suggesting impaired encoding of verbal information. In contrast, lack of rapid forgetting suggests relative absence of a storage deficit in bipolar patients. While severity of mood symptomatology and illness duration were not associated with task performance, gender and family history significantly affected memory function.

CONCLUSIONS

Results suggest that declarative memory impairments in bipolar patients: (1) are consistent with deficits in learning, but do not appear to be related to different organizational strategies during learning, and (2) do not appear to be secondary to clinical state, but rather may be associated with the underlying pathophysiology of the illness.

Attention deficits in bipolar disorder: a comparison based on the Continuous Performance Test

Although attentional deficits measured by Continuous Performance Tests (CPTs) have been observed in patients with bipolar disorder, their relationship with clinical state is not well understood. The identical pairs Continuous Performance Test (CPT-IP) shows particular promise as a measure sensitive to trait abnormalities in attentional function. In this study, the CPT-IP was administered to 27 patients with bipolar disorder (22 type I, 5 type II) and 25 demographically matched healthy comparison subjects, in order to assess the presence and nature of attentional deficits as a function of mood symptoms. Results showed significantly impaired CPT performance in bipolar patients compared with healthy subjects. Patients made fewer hits (p < 0.01), were slower to respond (p < 0.007), and had poorer discrimination (p < 0.05) and bias (p < 0.006) than comparison subjects. Severity of mania and depression was not correlated with any of the CPT measures. Our findings suggest that attentional dysfunction may be a trait deficit associated with bipolar illness. However, within-subjects longitudinal studies examining fluctuations in performance over time are needed.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of bipolar disorders, part III: maintenance treatment

As with the two preceding guidelines of this series, these practice guidelines for the pharmacological maintenance treatment of bipolar disorder were developed by an international task force of the World Federation of Societies of Biological Psychiatry (WFSBP). Their purpose is to supply a systematic overview of all scientific evidence relating to maintenance treatment. The data used for these guidelines were extracted from a MEDLINE and EMBASE search, from recent proceedings from key conferences and various national and international treatment guidelines. The scientific justification of support for particular treatments was categorised into four levels of evidence (A-D). As these guidelines are intended for clinical use, the scientific evidence was not only graded, but also reviewed by the experts of the task force to ensure practicality.

The effectiveness of divalproate in all forms of mania and the broader bipolar spectrum: many questions, few answers

Divalproate (VPA) was the first drug, other than lithium, reported to be efficacious for the treatment of bipolar disorder. Since then, the effectiveness of VPA, alone, in combination, and as maintenance therapy, has been investigated in a number of studies. As a monotherapy, clinical studies revealed that VPA was superior to lithium with regard to being effective in a broader patient population: patients with depressive symptoms concurrent with their mania, patients previously poorly responsive to lithium, patients with more lifetime episodes, and on specific symptoms of elation/grandiosity and reduced need for sleep. In addition, while VPA had superior efficacy versus carbamazepine (CBZ), an anti-manic agent, and equivalent efficacy to the anti-psychotic agent olanzapine (OLZ) in manic patients with psychotic manic features, patients showed much better tolerability to VPA than CBZ, anti-psychotics, and, in particular, lithium. Recently, combination therapy (mood stabilizers plus anti-psychotic agents) has shown some advantages compared with monotherapy. Manic symptoms have been observed to improve to a greater extent when the mood stabilizer was co-administered with an anti-psychotic rather than either agent used alone. While only a few maintenance studies have been conducted to date, two randomized studies have indicated consistent trends toward greater efficacy of VPA than lithium, and significant superiority over placebo on most, although not all, measures. In general, VPA provides a well-tolerated treatment that is efficacious for a broad spectrum of manic states and improves outcomes during maintenance treatment.

Real-time pharmacokinetics guiding clinical decisions

The purpose of this weekly schedule phase I study of liposome encapsulated paclitaxel (LEP) was to define the maximum-tolerated dose (MTD), the recommended dose (RD), the dose-limiting toxicities (DLTs), the pharmacokinetic profiles, and to evaluate preliminarily antitumour effects in patients with refractory solid malignancies. LEP was administered as an intravenous (i.v.) infusion over 45 min once every week for 6 out of 8 weeks. Fourteen patients were treated at doses ranging from 90 to 150 mg/m(2)/week. In one patient, DLT was observed at the dose level of 150 mg/m(2)/week, who received less than 70% of the intended cumulative dose. No cumulative toxicities were observed. Stabilisation of disease for 8 weeks was documented in two patients. The whole blood clearance of total paclitaxel was similar for LEP (15.3+/-8.98 l/h/m(2)) and Taxol (17.5+/-3.43 l/h/m(2)), and the extraliposomal to total drug ratio increased rapidly to unity at later sampling time points. The trial was discontinued upon completion of enrolment of the 150 mg/m(2)/week cohort because an assessment of the pharmacokinetics and clinical data suggested that LEP was unlikely to have any advantages over Taxol. It is concluded that this formulation of LEP is unlikely to provide improvements over the taxanes currently in clinical use.

Efficacy of olanzapine and olanzapine-fluoxetine combination in the treatment of bipolar I depression

BACKGROUND

Despite the longer duration of the depressive phase in bipolar disorder and the frequent clinical use of antidepressants combined with antipsychotics or mood stabilizers, relatively few controlled studies have examined treatment strategies for bipolar depression.

OBJECTIVE

To examine the use of olanzapine and olanzapine-fluoxetine combination in the treatment of bipolar I depression.

DESIGN

Double-blind, 8-week, randomized controlled trial.

SETTING

Eighty-four sites (inpatient and outpatient) in 13 countries. Patients A total of 833 randomized adults with bipolar I depression with a Montgomery-Asberg Depression Rating Scale (MADRS) score of at least 20. Intervention Patients were randomly assigned to receive placebo (n = 377); olanzapine, 5 to 20 mg/d (n = 370); or olanzapine-fluoxetine combination, 6 and 25, 6 and 50, or 12 and 50 mg/d (n = 86).

MAIN OUTCOME MEASURE

Changes in MADRS total scores using mixed-effects model repeated-measures analyses.

RESULTS

During all 8 study weeks, the olanzapine and olanzapine-fluoxetine groups showed statistically significant improvement in depressive symptoms vs the placebo group (P<.001 for all). The olanzapine-fluoxetine group also showed statistically greater improvement than the olanzapine group at weeks 4 through 8. At week 8, MADRS total scores were lower than at baseline by 11.9, 15.0, and 18.5 points in the placebo, olanzapine, and olanzapine-fluoxetine groups, respectively. Remission criteria were met by 24.5% (87/355) of the placebo group, 32.8% (115/351) of the olanzapine group, and 48.8% (40/82) of the olanzapine-fluoxetine group. Treatment-emergent mania (Young Mania Rating Scale score <15 at baseline and > or =15 subsequently) did not differ among groups (placebo, 6.7% [23/345]; olanzapine, 5.7% [19/335]; and olanzapine-fluoxetine, 6.4% [5/78]). Adverse events for olanzapine-fluoxetine therapy were similar to those for olanzapine therapy but also included higher rates of nausea and diarrhea.

CONCLUSIONS

Olanzapine is more effective than placebo, and combined olanzapine-fluoxetine is more effective than olanzapine and placebo in the treatment of bipolar I depression without increased risk of developing manic symptoms.

Rationale, design, and methods of the systematic treatment enhancement program for bipolar disorder (STEP-BD)

The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) was conceived in response to a National Institute of Mental Health initiative seeking a public health intervention model that could generate externally valid answers to treatment effectiveness questions related to bipolar disorder. STEP-BD, like all effectiveness research, faces many design challenges, including how to do the following: recruit a representative sample of patients for studies of readily available treatments; implement a common intervention strategy across diverse settings; determine outcomes for patients in multiple phases of illness; make provisions for testing as yet undetermined new treatments; integrate adjunctive psychosocial interventions; and avoid biases due to subject drop-out and last-observation-carried-forward data analyses. To meet these challenges, STEP-BD uses a hybrid design to collect longitudinal data as patients make transitions between naturalistic studies and randomized clinical trials. Bipolar patients of every subtype with age >/= 15 years are accessioned into a study registry. All patients receive a systematic assessment battery at entry and are treated by a psychiatrist (trained to deliver care and measure outcomes in patients with bipolar disorder) using a series of model practice procedures consistent with expert recommendations. At every follow-up visit, the treating psychiatrist completes a standardized assessment and assigns an operationalized clinical status based on DSM-IV criteria. Patients have independent evaluations at regular intervals throughout the study and remain under the care of the same treating psychiatrist while making transitions between randomized care studies and the standard care treatment pathways. This article reviews the methodology used for the selection and certification of the clinical treatment centers, training study personnel, the general approach to clinical management, and the sequential treatment strategies offered in the STEP-BD standard and randomized care pathways for bipolar depression and relapse prevention.

The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders, Part II: Treatment of Mania

Identical to the preceding guidelines of this series, these practice guidelines for the biological, mainly pharmacological treatment of acute bipolar mania were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). Their purpose is to supply a systematic overview of all scientific evidence pertaining to the treatment of acute mania. The data used for these guidelines have been extracted from a MEDLINE and EMBASE search, from recent proceedings of key conferences, and from various national and international treatment guidelines. Their scientific rigor was categorised into four levels of evidence (A-D). As these guidelines are intended for clinical use, the scientific evidence was finally not only graded, but has also been commented by the experts of the task force to ensure practicability. Key words: bipolar disorder, mania, acute treatment, evidence-based guidelines, pharmacotherapy, antipsychotics, mood stabiliser, electroconvulsive therapy.

An open-label trial of divalproex in children and adolescents with bipolar disorder

OBJECTIVE

This study evaluated the safety and effectiveness of divalproex sodium (Depakote ) in the treatment of youths with bipolar disorder.

METHOD

Forty bipolar disorder patients aged 7 to 19 years, with a manic, hypomanic, or mixed episode, enrolled in an open-label study of divalproex (2-8 weeks), followed by a double-blind, placebo-controlled period (8 weeks).

RESULTS

Twenty-two subjects (61%) showed > or =50% improvement in Mania Rating Scale (MRS) scores during the open-label period. Significant ( <.001) improvements from baseline were seen for mean scores of all efficacy measures, including the MRS, Manic Syndrome Scale, Behavior and Ideation Scale, Brief Psychiatric Rating Scale, Clinical Global Impressions Severity scale, and Hamilton Rating Scale for Depression. Of the 23 subjects who discontinued the study during the open-label period, 6 (15%) discontinued for ineffectiveness, 6 (15%) for intolerance, 6 (15%) for noncompliance, and 6 (15%) for other reasons. Adverse events were generally mild or moderate in severity, with the most common being headache, nausea, vomiting, diarrhea, and somnolence. Laboratory data results were unremarkable. Too few subjects participated in the double-blind period for statistical analysis.

CONCLUSION

This study provides preliminary support for the safety and effectiveness of divalproex in the treatment of bipolar disorder in youths.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of bipolar disorders. Part I: Treatment of bipolar depression

These practice guidelines for the biological, mainly pharmacological treatment of bipolar depression were developed by an international task force of the World Federation of Societies of Biological Psychiatry (WFSBP). Their purpose is to supply a systematic overview of all scientific evidence pertaining to the treatment of bipolar depression. The data used for these guidelines have been extracted from a MEDLINE and EMBASE search, and from recent proceedings of key conferences and various national and international treatment guidelines. Their scientific rigor was categorised into four levels of evidence (A-D). As these guidelines are intended for clinical use, the scientific evidence was not only graded, but also commented on by the experts of the task force to ensure practicability.

Spatio-temporal instabilities for counterpropagating waves in periodic media

Nonlinear evolution of coupled forward and backward fields in a multi-layered film is numerically investigated. We examine the role of longitudinal and transverse modulation instabilities in media of finite length with a homogeneous nonlinear susceptibility <font face="Symbol">c</font>((3)). The numerical solution of the nonlinear equations by a beam-propagation method that handles backward waves is described.

Quantum properties of optical field in photonic band gap structures

A theoretical analysis of the quantum behaviour of radiation field's propagation in photonic band gaps structures is performed. In these initial calculations we consider linear inhomogeneous and nondispersive media.

Characterization of the antitumor effects of the selective farnesyl protein transferase inhibitor R115777 in vivo and in vitro

R115777 [(B)-6-[amino(4-chlorophenyl)(1-methyl-1H-imidazol-5-yl)-methyl]-4-(3-chlorophenyl)-1-methyl-2(1H)-quinolinone] is a potent and selective inhibitor of farnesyl protein transferase with significant antitumor effects in vivo subsequent to oral administration in mice. In vitro, using isolated human farnesyl protein transferase, R115777 competitively inhibited the farnesylation of lamin B and K-RasB peptide substrates, with IC50s of 0.86 nM and 7.9 nM, respectively. In a panel of 53 human tumor cell lines tested for growth inhibition, approximately 75% were found to be sensitive to R115777. The majority of sensitive cell lines had a wild-type ras gene. Tumor cell lines bearing H-ras or N-ras mutations were among the most sensitive of the cell lines tested, with responses observed at nanomolar concentrations of R115777. Tumor cell lines bearing mutant K-ras genes required higher concentrations for inhibition of cell growth, with 50% of the cell lines resistant to R115777 up to concentrations of 500 nM. Inhibition of H-Ras, N-Ras, and lamin B protein processing was observed at concentrations of R115777 that inhibited cell proliferation. However, inhibition of K-RasB protein-processing could not be detected. Oral administration b.i.d. of R115777 to nude mice bearing s.c. tumors at doses ranging from 6.25-100 mg/kg inhibited the growth of tumors bearing mutant H-ras, mutant K-ras, and wild-type ras genes. Histological evaluations revealed heterogeneity in tumor responses to R115777. In LoVo human colon tumors, treatment with R115777 produced a prominent antiangiogenic response. In CAPAN-2 human pancreatic tumors, an antiproilferative response predominated, whereas in C32 human melanoma, marked induction of apoptosis was observed. The heterogeneity of histological changes associated with antitumor effects suggested that R115777, and possibly farnesyl protein transferase inhibitors as a class, alter processes of transformation related to tumor-host interactions in addition to inhibiting tumor-cell proliferation.

A phase II pilot study of KW-2189 in patients with advanced renal cell carcinoma

BACKGROUND

KW-2189 is a semi-synthetic, water-soluble analog of duocarmycin B2, a new class of potent antitumor antibiotics produced by streptomyces, with improved in vitro antitumor potency.

PATIENTS AND METHODS

Forty patients with pathologically confirmed metastatic renal cell carcinoma were treated in this multicenter, open-label phase II trial. All patients received 0.4 mg/m2 KW-2189 as an i.v. infusion for Cycle I. Cycles were repeated every 5 to 6 weeks with escalations to 0.5 mg/m2 in the absence of significant toxicity or disease progression.

RESULTS

No patient had an objective response. The most common drug-related toxicity was hematological-delayed neutropenia and thrombocytopenia, with recovery by week 6. Non-hematologic toxicity consisted of mild to moderate fatigue, nausea and vomiting, and anorexia that was generally manageable.

CONCLUSIONS

KW-2189 in this dose and schedule has a predictable safety profile of reversible myelosuppression. No activity in metastatic renal cell carcinoma was demonstrated.

Strategies for implementing lipid-lowering therapy: pharmacy-based approach

A multidisciplinary program was designed to improve patient outcomes after an acute coronary event. The primary objective of the program was that lipid-lowering therapy be prescribed at the time of discharge for acute myocardial infarction (AMI) and percutaneous transluminal coronary angioplasty (PTCA) patients. Secondary objectives for this program were (1) a baseline lipid panel within the first 24 hours of admission and (2) documentation of discharge counseling for lipid-lowering therapy in the patient medical record. Improvements were reported for all 3 objectives. For the primary indicator, lipid-lowering therapy prescribed at discharge, the baseline value increased from 40% to 72-81%. The percentage of patients with a lipid panel within 24 hours of admission improved from a baseline of 13% to 38-71%. Overall, 28-77% of patient records contained documentation of lipid-lowering medication counseling after initiation of the program. This information should provide the necessary benchmarking data to maintain competitiveness in the dynamic healthcare environment. Overall, this program provides high-quality, cost-effective health care for the patient with established coronary artery disease.

Phase I and pharmacokinetic study of farnesyl protein transferase inhibitor R115777 in advanced cancer

PURPOSE

To determine the maximum-tolerated dose, toxicities, and pharmacokinetic profile of the farnesyl protein transferase inhibitor R115777 when administered orally bid for 5 days every 2 weeks.

PATIENTS AND METHODS

Twenty-seven patients with a median age of 58 years received 85 cycles of R115777 using an intrapatient and interpatient dose escalation schema. Drug was administered orally at escalating doses as a solution (25 to 850 mg bid) or as pellet capsules (500 to 1300 mg bid). Pharmacokinetics were assessed after the first dose and the last dose administered during cycle 1.

RESULTS

Dose-limiting toxicity of grade 3 neuropathy was observed in one patient and grade 2 fatigue (decrease in two performance status levels) was seen in four of six patients treated with 1,300 mg bid. The most frequent clinical grade 2 or 3 adverse events in any cycle included nausea, vomiting, headache, fatigue, anemia, and hypotension. Myelosuppression was mild and infrequent. Peak plasma concentrations of R115777 were achieved within 0.5 to 4 hours after oral drug administration. The elimination of R115777 from plasma was biphasic, with sequential half-lives of about 5 hours and 16 hours. There was little drug accumulation after bid dosing, and steady-state concentrations were achieved within 2 to 3 days. The pharmacokinetics were dose proportional in the 25 to 325 mg/dose range for the oral solution. Urinary excretion of unchanged R115777 was less than 0.1% of the oral dose. One patient with metastatic colon cancer treated at the 500-mg bid dose had a 46% decrease in carcinoembryonic antigen levels, improvement in cough, and radiographically stable disease for 5 months.

CONCLUSION

R115777 is bioavailable after oral administration and has an acceptable toxicity profile. Based upon pharmacokinetic data, the recommended dose for phase II trials is 500 mg orally bid (total daily dose, 1, 000 mg) for 5 consecutive days followed by 9 days of rest. Studies of continuous dosing and studies of R115777 in combination with chemotherapy are ongoing.

A gene associated with filamentous growth in Ophiostoma novo-ulmi has RNA-binding motifs and is similar to a yeast gene involved in mRNA splicing

The COL1 gene was isolated from Ophiostoma novo-ulmi using the techniques of insertional mutagenesis and plasmid rescue. Sequence analyses suggest that the COL1 gene encodes a unique protein of 826 amino acids with consensus-type RNA-binding domains, most similar to a putative protein from Schizosaccharomyces pombe which resembles the C-terminus of the Saccharomyces cerevisiae U4/U6 splicing factor PRP24. Disruption of the COL1 gene produced the yeast-like col1 mutant. The inability of the mutant to synthesize the COL1 gene product was confirmed by transcript analysis. Transformation of the col1 mutant with the COL1 gene restored the wild phenotype and production of the 4.0-kb mRNA. The results from this study demonstrate that the COL1 RNA-binding protein is associated with filamentous growth in O. novo-ulmi.

Decreased dopamine beta-hydroxylase activity in unipolar geriatric delusional depression

BACKGROUND

Decreased dopamine beta-hydroxylase (DBH) activity has been reported in unipolar psychotic depression. DBH comparisons between elderly delusional and nondelusional depressives and controls and determination of whether pretreatment group differences persist have not been reported. Our objective was to compare DBH activity in elderly delusional major depressives with that of nondelusional depressives and normal control subjects before and after hospital treatment.

METHODS

Enzyme activity was assessed after hospital admission. A subsample had predischarge assessments. Treatment was not controlled but accounted for in analyses. Electroconvulsive therapy subjects were medication-free for posttreatment assays.

RESULTS

Baseline and predischarge DBH assays were lower in subjects with delusional depression than in either comparison group. Despite high intraindividual correlation, treatment was associated with significant increases in activity in the clinical groups.

CONCLUSIONS

Patients with late-life delusional depression have lower DBH activity before and after hospital treatment than age-matched nondelusional patients or normal controls.

Chemopreventive effects of the aromatase inhibitor vorozole (R 83842) in the methylnitrosourea-induced mammary cancer model

The chemopreventive activity of the highly specific nonsteroidal aromatase inhibitor, vorozole, was examined in the methylnitrosourea (MNU)-induced rat model of mammary carcinogenesis. Various doses of vorozole (0.08-1.25 mg/kg body wt/day) were administered daily (by gavage) to female Sprague-Dawley rats starting at 43 days of age. Seven days later, the rats were given a single i.v. dose of MNU (50 mg/kg body wt). Rats were continually treated with vorozole until the end of the experiment (120 days post-MNU). Vorozole caused a dose dependent inhibition of mammary cancer multiplicity. The highest dose of vorozole (1.25 mg/kg body wt/day) decreased cancer multiplicity by approximately 90%, and simultaneously decreased cancer incidence from 100 to 44%. The next two highest doses of vorozole (0.63 and 0.31 mg/kg body wt/day) inhibited MNU-induced mammary cancer multiplicity by 70-80%. Even the two lowest doses of vorozole (0.16 and 0.08 mg/kg body wt/ day) decreased cancer multiplicity -50%. Serum level determinations were performed on a variety of endpoints at either 4 or 24 h following the last dose of vorozole. Insulin-like growth factor (IGF)-1 levels were slightly, but significantly, increased by vorozole treatment. Vorozole induced striking increases in serum testosterone levels at 4 h at all the dose levels employed. Testosterone levels were significantly elevated over controls at 24 h in rats given the lower doses of vorozole (0.08-0.31 mg/kg body wt/day), but were significantly lower than in rats administered the higher doses of vorozole (0.63 or 1.25 mg/kg body wt/ day). This result presumably reflects the limited half-life of vorozole in rats. In a second series of experiments, the effects of limited duration of dosing with vorozole (2.5 mg/kg body wt/day) or intermittent dosing with vorozole were determined. Treatment of rats with vorozole for limited time periods, from 3 days post-MNU administration until 30 or 60 days post-MNU treatment, resulted in significant delays in the time to appearance of palpable cancers. However, these limited treatments did not greatly affect the overall incidence or multiplicity of mammary cancers when compared with the MNU controls at the end of the study (150 days post-MNU). Finally, the effects of intermittent dosing with vorozole (2.5 mg/kg body wt/day) were examined. Rats were administered cycles of vorozole daily for a period of 3 weeks followed by treatment with the vorozole vehicle for the next 3 weeks (total of four cycles). Although this intermittent treatment did inhibit the appearance of new tumors during each of the periods that vorozole was administered, it did not cause regression of palpable cancers.

Incorporation of [3H]valproic acid into lipids in GT1-7 neurons

Valproic acid (2-propylpentanoic acid, valproate, VPA), an 8-carbon, branched chain fatty acid, is effectively used in the treatment of mania and epilepsy. The biochemical mechanisms by which this drug has its therapeutic effects are not yet established. The purpose of this study was to partially characterize the incorporation of [3H]VPA into phospholipids of GT1-7 neurons, an immortalized hypothalamic cell line. GT1-7 neurons were grown to confluence in culture dishes, and then were incubated with various concentrations of [3H]VPA between 10 and 400 microg/mL for various times up to 20 hr. Total lipids were extracted and phospholipids were separated from neutral lipids using TLC. Our results indicate that [3H]VPA (10 microg/mL) was incorporated into phospholipids of GT1-7 neurons in a time-dependent and saturable manner over 300 min. Subsequent separation of the lipid fraction by TLC indicated that 44.4% of the radioactivity taken up by the cells was incorporated into phospholipids and neutral lipids. One of the phospholipids migrated with a slightly lower Rf value than authentic phosphatidylcholine. Our results show that the incorporation of VPA into phospholipids and glycerides was linear with VPA concentrations from 10 to 400 microg/mL. Finally, we synthesized 1-acyl-2-valproyl-sn-glycero-3-phosphocholine and validated its structure with nuclear magnetic resonance and electrospray mass spectrometry to verify the structure of this compound, confirming that this compound is structurally possible. We conclude that VPA is incorporated into lipids in GT1-7 neurons and discuss the possible effects of valproyl phospholipids on neuronal functional properties.

Dopamine uptake sites, labelled with [3H]GBR12935, in brain samples from depressed suicides and controls

We have quantitated dopamine uptake sites, labelled with [3H]GBR12935, in caudate, putamen and nucleus accumbens of suicides with a retrospective diagnosis of depression, and age and gender-matched controls. Suicides were subdivided into those who had been free of antidepressant drugs for at least three months, and those in whom prescription of antidepressant drugs was clearly documented. We found no significant differences between controls and suicides overall, or when the suicides were divided on the basis of antidepressant treatment or violence of death. A significant negative correlation between the number of dopamine uptake sites and age was found in each region studied. Our results suggest dopamine uptake sites are not critically involved in depression or antidepressant drug action.