Dialectical behaviour therapy: effect of a coordinated implementation approach on programme sustainability

Sustainability of DBT programmes and the factors which potentially influence this has received little attention from researchers. In this article, we review the literature reporting on sustainability of DBT programmes in outpatient settings. We also seek to advance the limited knowledge on this topic by reporting on the sustainability of DBT programmes delivered by teams that trained via a coordinated implementation approach in Ireland. As part of this perspective piece we conducted a systematic literature search which identified four studies reporting on DBT programme sustainability. All four reported on programmes delivered by teams that had received training as per the DBT Intensive Training Model. The findings of these studies are summarised and we consider the effect on DBT programme sustainability of introducing a coordinated implementation approach in Ireland.

Service user perspectives on social prescribing services for mental health in the UK: a systematic review

AIM

To thematically synthesise adult service users' perspectives on how UK-based social prescribing services support them with their mental health management.

METHODS

Nine databases were systematically searched up to March 2022. Eligible studies were qualitative or mixed methods studies involving participants aged ⩾ 18 years accessing social prescribing services primarily for mental health reasons. Thematic synthesis was applied to qualitative data to create descriptive and analytical themes.

RESULTS

51,965 articles were identified from electronic searches. Six studies were included in the review (n = 220 participants) with good methodological quality. Five studies utilised a link worker referral model, and one study a direct referral model. Modal reasons for referral were social isolation and/or loneliness (n = 4 studies). Two analytical themes were formulated from seven descriptive themes: (1) person-centred care was key to delivery and (2) creating an environment for personal change and development.

CONCLUSIONS

This review provides a synthesis of the qualitative evidence on service users' experiences of accessing and using social prescribing services to support their mental health management. Adherence to principles of person-centred care and addressing the holistic needs of service users (including devoting attention to the quality of the therapeutic environment) are important for design and delivery of social prescribing services. This will optimise service user satisfaction and other outcomes that matter to them.

221 PREVALENCE AND DOCUMENTATION OF DELIRIUM IN A UNIVERSITY HOSPITAL

Background

Delirium can complicate approximately 10% of all medical admissions and prevalence increases in those with cognitive impairment, increasing age and medical complexity. Delirium is associated with increased morbidity and mortality as well as increased length of stay. Prompt recognition and treatment is essential. The National Delirium Care Bundle suggests assessment and recognition at the earliest opportunity and documentation of delirium if patients screen positive.

Methods

We carried out an audit among patients admitted in all medical wards to identify delirium and assess if it was documented and a care bundle opened. All patients were screened using the 4AT tool at least once over the space of one week. Medical notes were also screened to assess for documentation of delirium.

Results

95 patients were screened and 32 (33%) of these screened positive. Of these only 11 patients had a diagnosis of delirium documented in medical/nursing notes and a delirium care bundle opened. 50% of CCU patients were delirious. The Geriatric Medicine Ward had a lower prevalence of 19% with 66% identified in medical notes.

Conclusion

These results are disappointing with only 34% of patients identified as having a delirium. This audit is part of a quality improvement project with education sessions ongoing and roll out of the national delirium/dementia pathways across the medical wards. We hope to present our interventions and completed audit loop shortly.

The sourcing and use of high physical resemblance personal protective equipment to train healthcare workers, improve confidence and conserve medical-grade equipment

Personal protective equipment (PPE) is essential for healthcare worker (HCW) safety. Conservation of PPE for clinical use during the COVID-19 pandemic reduced its availability for training, necessitating an innovative approach to sourcing high physical resemblance PPE (HPR-PPE). We present a case study of crowd-sourcing of HPR-PPE to train HCWs. Survey results indicated that HPR-PPE enabled high-fidelity practise of PPE application and removal, aided procedure recall, improved user confidence and was sufficiently similar to medical-grade PPE. HPR-PPE provided a novel and cost-effective alternative. We also demonstrated that medical-grade PPE can be sourced from non-medical institutions and businesses during a pandemic.

Pharmaceutical industry interactions of psychiatric trainees from 20 European countries

Background:

Interactions between the pharmaceutical industry (PI) and psychiatrists have been under scrutiny recently, though there is little empirical evidence on the nature of the relationship and its intensity at psychiatry trainee level. We therefore studied the level of PI interactions and the underlying beliefs and attitudes in a large sample of European psychiatric trainees.

Methods:

One thousand four hundred and forty-four psychiatric trainees in 20 European countries were assessed cross-sectionally, with a 62-item questionnaire.

Results:

The total number of PI interactions in the preceding two months varied between countries, with least interactions in The Netherlands (M (Mean) = 0.92, SD = 1.44, range = 0–12) and most in Portugal (M = 19.06, SD = 17.44, range = 0–100). Trainees were more likely to believe that PI interactions have no impact on their own prescribing behaviour than that of other physicians (M = 3.30, SD = 1.26 vs. M = 2.39, SD = 1.06 on a 5-point Likert scale: 1 “completely disagree” to 5 “completely agree”). Assigning an educational role to the pharmaceutical industry was associated with more interactions and higher gift value (IRR (incidence rate ratio) = 1.21, 95%CI = 1.12–1.30 and OR = 1.18, 95%CI = 1.02–1.37).

Conclusions:

There are frequent interactions between European psychiatric trainees and the PI, with significant variation between countries. We identified several factors affecting this interaction, including attribution of an educational role to the PI. Creating alternative educational opportunities and specific training dedicated to PI interactions may therefore help to reduce the impact of the PI on psychiatric training.

CTA in acute stroke: short intensive training intervention is highly effective in improving radiologists' performance

AIM

To determine whether focussed radiology training in reporting stroke computed tomography angiography (CTA) improved diagnostic performance of general radiology specialty trainees staffing regional on call rotas.

MATERIALS AND METHODS

A validated case archive (VCA) consisting of 50 hyperacute stroke CTA cases was developed for a full day course on CTA interpretation. Training days were organised ensuring all local trainees had a chance to attend. The rate of major and minor amendments by neuroradiology consultants were reviewed in 252 on-call radiology trainee reports.

RESULTS

Before training, radiology trainees had a total discrepancy (reporting error) rate of 37%: 12% major, 25% minor. Following CTA training, the total discrepancy rate was not significantly reduced (34%) but there was a substantial reduction in major discrepancies to 4% (p=0.037; odds ratio=3.30, 95% confidence interval [CI]: 1.08 to 10.12).

CONCLUSION

An intensive training course based on a hyperacute stroke VCA significantly reduced major discrepancies in stroke CTA interpretation for radiology trainees. The ability of radiology trainees to recognise large vessel occlusions and other significant findings improved.

Successful behavioural strategies to increase physical activity and improve glucose control in adults with Type 2 diabetes

AIMS

To explore which behaviour change techniques and other intervention features are associated with increased levels of physical activity and improved HbA1c in adults with Type 2 diabetes.

METHODS

Moderator analyses were performed on a dataset of 21 behaviour change techniques and six intervention features identified in a systematic review of behavioural interventions (N = 1975 patients with Type 2 diabetes) to establish their associations with changes in physical activity and HbA1c .

RESULTS

Four behaviour change techniques (prompt focus on past success, barrier identification/problem-solving, use of follow-up prompts and provide information on where and when to perform physical activity) had statistically significant associations with increased levels of physical activity. Prompt review of behavioural goals and provide information on where and when to perform physical activity behaviour had statistically significant associations with improved HbA1c . Pedometer use was associated with decreased levels of physical activity.

CONCLUSIONS

These data suggest that clinical care teams can optimise their consultations by incorporating specific behaviour change techniques that are associated with increased levels of physical activity and improved long-term glycaemic control.

Abstract P4-15-12: Rebastinib in combination with eribulin ablates TIE2-expressing macrophages, reduces metastasis, and increases survival in the PyMT metastatic breast cancer model

In cancer models, TIE2 kinase plays an important role in angiogenesis, vasculogenesis, and tumor metastasis. TIE2 expression is largely restricted to vascular endothelial cells, tissue macrophages, and bone marrow derived TIE2-expressing monocytes (TEMs), which are proangiogenic, provasculogenic and enhance invasiveness. The hypoxic tumor environment engendered by damaging the vasculature with chemotherapy, radiation, or anti-angiogenic treatments leads to rebound tumor vascularization by an angiogenic switch from the VEGF pathway to the angiopoietin/TIE2 pathway. This leads to recruitment of provasculogenic TEMs from the bone marrow, leading to the growth of residual tumor cells and disease progression. Significantly, a subset of TIE2-expressing macrophages are located within specialized vascular structures known as tumor microenvironment for metastases (TMEMs). Recent observations have linked TIE2-expressing macrophages within TMEM structures to intravasation of cancer cells into circulation and subsequent dissemination to metastatic sites. We hypothesized that TIE2 inhibition should decrease migration and association of TEMs with blood vessels in the tumor stroma, therefore blocking their proangiogenic activity and leading to reduced tumor growth. TIE2 inhibition may also alter TMEM function, leading directly to a blockade of metastasis.

Rebastinib is a picomolar inhibitor of TIE2 kinase, and exhibits an extraordinarily long off-rate from TIE2, measured to be over 24 hours in a cell-based assay. Herein, we examine the efficacy of rebastinib in the polyoma middle-T antigen (PyMT) syngeneic mouse breast cancer model. In this model, PyMT breast cancer cells are implanted in the mammary fat pad, and primary tumor growth leads to metastasis, which is known to be modulated by TEMs and TMEM vascular structures. We examined dosing rebastinib in combination with eribulin, an inhibitor of microtubule dynamics that recently was FDA-approved for treatment-refractory metastatic breast cancer. Rebastinib treatment in this model significantly ablated TEMs in the primary tumor stroma and caused a significant decrease in lung metastases. Furthermore, the combination of rebastinib and eribulin led to a significant further decrease in lung metastases compared to treatment with eribulin alone (Table 1). Rebastinib also enhanced the activity of eribulin in reducing primary tumor growth and regrowth of tumor post-resection.

TIE2 inhibition represents a novel treatment approach for metastatic breast cancer and other cancers that rely on TEMs and TMEMs for growth and metastasis. As such, rebastinib has been selected for further clinical development in combination with eribulin for treatment-refractory metastatic breast cancer, with a Phase 1b trial being planned for late 2013.

Rebastinib reduces lung metastases in the PyMT breast cancer modelTreatmentLung Metastases (% of Control)Vehicle100%Eribulin 1 mg/kg three times/week71%Rebastinib 10 mg/kg twice/week + Eribulin 1 mg/kg23%Eribulin 0.3 mg/kg three times/week71%Rebastinib 10 mg/kg twice/week + Eribulin 0.3 mg/kg51%Eribulin 0.1 mg/kg three times/week72%Rebastinib 10 mg/kg twice/week + Eribulin 0.1 mg/kg43%

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-15-12.

Abstract P4-15-13: Rebastinib in combination with paclitaxel ablates TIE2-expressing macrophages, reduces metastasis, and increases survival in the PyMT metastatic breast cancer model

In cancer models, TIE2 kinase plays an important role in angiogenesis, vasculogenesis, and tumor metastasis. TIE2 expression is largely restricted to vascular endothelial cells, tissue macrophages, and bone marrow derived TIE2-expressing monocytes (TEMs), which are proangiogenic, provasculogenic and enhance invasiveness. The hypoxic tumor environment engendered by damaging the vasculature with chemotherapy, radiation, or anti-angiogenic treatments leads to rebound tumor vascularization by an angiogenic switch from the VEGF pathway to the angiopoietin/TIE2 pathway. This leads to recruitment of provasculogenic TEMs from the bone marrow, leading to the growth of residual tumor cells and disease progression. Significantly, a subset of TIE2-expressing macrophages are located within specialized vascular structures known as tumor microenvironment for metastases (TMEMs). Recent observations have linked TIE2-expressing macrophages within TMEM structures to intravasation of cancer cells into circulation and subsequent dissemination to metastatic sites. We hypothesized that TIE2 inhibition should decrease migration and association of TEMs with blood vessels in the tumor stroma, therefore blocking their proangiogenic activity and leading to reduced tumor growth. TIE2 inhibition may also alter TMEM function, leading directly to a blockade of metastasis.

Rebastinib is a picomolar inhibitor of TIE2 kinase, and exhibits an extraordinarily long off-rate from TIE2, measured to be over 24 hours in a cell-based assay. Herein, we examine the efficacy of rebastinib in the polyoma middle-T antigen (PyMT) syngeneic mouse breast cancer model. In this model, PyMT breast cancer cells are implanted in the mammary fat pad, and primary tumor growth leads to metastasis, which is known to be modulated by TEMs and TMEM vascular structures. We examined multiple dosing schedules of rebastinib in combination with paclitaxel. Rebastinib treatment in this model significantly ablated TEMs in the primary tumor stroma and caused a significant decrease in lung metastases (Table 1). Furthermore, the combination of rebastinib and paclitaxel led to a significant further decrease in lung metastases compared to treatment with paclitaxel or rebastinib alone. Rebastinib also enhanced the activity of paclitaxel in reducing primary tumor growth and regrowth of tumor post-resection.

TIE2 inhibition with targeted therapy represents a novel treatment approach for metastatic breast cancer and other cancers that rely on TEMs and TMEMs for growth and metastasis. As such, rebastinib has been selected for further clinical development for treatment-refractory metastatic breast cancer, with a Phase 1b trial being planned for late 2013.

Rebastinib reduces lung metastases in the PyMT breast cancer modelStudynTreatmentLung Metastases (% of Control)110Vehicle100%110Paclitaxel 10 mg/kg Q5D36%110Rebastinib 10 mg/kg BID28%110Rebastinib 10 mg/kg BID + Paclitaxel7%210Vehicle100%210Paclitaxel 10 mg/kg Q5D51%210Rebastinib 10 mg/kg QD + Paclitaxel21%33Vehicle100%33Paclitaxel 10 mg/kg Q5D58%33Rebastinib 10 mg/kg twice/week + Paclitaxel28%

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-15-13.

Evaluation of an innovative recruitment initiative on the attitudes of medical students

Some medical specialties struggle to recruit sufficient trainees to their postgraduate programmes. In many countries including Ireland, psychiatry is one of these specialties. A psychiatric summer school was developed by the trainee committee of the College of Psychiatry of Ireland as a recruitment initiative. All applicants were invited to complete a questionnaire prior, on the day of and three months after the summer school assessing their attitudes to a career in psychiatry. The mean score on the modified Nielson questionnaire in the pre-summer school group was 26.7 (SD +/- 3.8) and this rose significantly 28.3 (SD +/- 3.2) after completion of the summer school. 64% (n = 31) of applicants to the Summer school expressed an interest in a career in psychiatry. This rose to 88% (n = 32) of those who attended. The findings of this study have national and international interest for all specialties who are struggling to recruit to their field.

Targeting the KIT activating switch control pocket: a novel mechanism to inhibit neoplastic mast cell proliferation and mast cell activation

Activating mutations in the receptor tyrosine kinase KIT, most notably KIT D816V, are commonly observed in patients with systemic mastocytosis. Thus, inhibition of KIT has been a major focus for treatment of this disorder. Here we investigated a novel approach to such inhibition. Utilizing rational drug design, we targeted the switch pocket (SP) of KIT which regulates its catalytic conformation. Two SP inhibitors thus identified, DP-2976 and DP-4851, were examined for effects on neoplastic mast cell proliferation and mast cell activation. Autophosphorylation of both wild type (WT) and, where also examined, KIT D816V was blocked by these compounds in transfected 293T cells, HMC 1.1 and 1.2 human mast cell lines; and in CD34⁺-derived human mast cells activated by stem cell factor (SCF). Both inhibitors induced apoptosis in the neoplastic mast cell lines and reduced survival of primary bone marrow mast cells from patients with mastocytosis. Moreover, the SP inhibitors more selectively blocked SCF potentiation of FcεRI-mediated degranulation. Overall, SP inhibitors represent an innovative mechanism of KIT inhibition whose dual suppression of KIT D816V neoplastic mast cell proliferation and SCF enhanced mast cell activation may provide significant therapeutic benefits.

The utility of a multimedia education program for prostate cancer patients: a formative evaluation

A multimedia program (MMP) was developed to educate patients with prostate cancer about their disease. A within-subjects design was used to investigate the changes in levels of cancer-related knowledge, psychosocial functioning, treatment decision-making role and information needs immediately after browsing the MMP. The participants were 67 men recently diagnosed with prostate cancer. Psychosocial functioning was assessed with 20 items describing common emotional states and coping strategies employed by cancer patients. Treatment decision-making role was assessed with the Control Preference Scale. A principle component analysis of the 20 psychosocial items yielded three components: distress, positive approach and nonacceptance. After browsing the MMP significant increases in knowledge and reductions in distress were reported. Marital status was significantly associated with knowledge gain. Married men and those attending the study session with their spouse displayed a significant shift towards a more active role in treatment decisions. The majority of information needs were fulfilled by the MMP; however, information related to the likelihood of a cure, treatment side effects, coping strategies and aetiology were not completely satisfied by the MMP. Implications of the findings and suggestions for future work on the design and evaluation of the MMP are discussed.

The status of evidence and outcomes in Stages of Change research

The Stages of Change model has become a prominent feature within health promotion and most of the literature associated with the model portrays it as being 'effective'. Based on an extensive review of the literature, this paper suggests that contrary to this view, there exist a relative paucity of sufficiently strong supportive evidence. The paper describes the features of the existing evidence base, and highlights problems in relation to various aspects of design and execution. Two wider issues relating to the core nature of the model and the evidence associated with it are identified as important and discussed. Two main conclusions are drawn. First, better quality quantitative outcome studies are needed. These should be complemented with significant qualitative case studies with a focus on practitioner and organizational utilization of the model. Second, the disproportionate popularity of the model may be skewing the practical and conceptual nature of health promotion. Stages of Change activities are seen to equate to 'health promotion' at the expense of other activities and approaches.

Evaluation of individual subjects in the analog classroom setting: I. Examples of graphical and statistical procedures for within-subject ranking of responses to different delivery patterns of methylphenidate

In this article, we describe graphical and statistical methods developed to evaluate the response patterns of individual children with attention deficit hyperactivity disorder (ADHD) to different conditions of treatment with stimulant medication. We used data from an investigation of drug delivery patterns to demonstrate these methods. Thirty-one children with ADHD participated in a double-blind crossover study of four conditions (three patterns of delivery of methylphenidate and a placebo control). In each condition, the children were evaluated across an 11-hour (7:00 a.m. to 6:00 p.m.) laboratory school day, and ratings of classroom behavior were obtained at regular intervals across the day. Graphical procedures were developed to display, for each individual, time courses of multiple measures of behavior taken across each double-blind test day. Expert clinicians judged these graphs and used this information to rank-order the test days from best to worst. A within-subject variant of Kendall's W was used to evaluate, for each subject, whether the rankings of these multidimensional graphs were reliable (concordant) across judges. A generalized kappa statistic was used to evaluate, for each condition, the reliability of the judges' rankings across subjects. Friedman's analysis of variance of ranks was used to evaluate, for the study, whether the conditions differed in terms of the average (consensus) rank assigned by the judges.

Acute tolerance to methylphenidate in the treatment of attention deficit hyperactivity disorder in children

OBJECTIVES

To evaluate the efficacy of several drug delivery patterns of methylphenidate and to determine whether acute tolerance develops to this widely used stimulant medication in the treatment of children with attention deficit hyperactivity disorder.

METHODS

Double-blind trials were conducted in a laboratory school setting in which multiple measures of efficacy were obtained frequently in the morning and afternoon across the school day. In study I, relative efficacy was determined for three dosing patterns of methylphenidate: a standard twice-daily profile, a flat profile, and an ascending profile. In study II, tolerance was assessed by comparison of three-times-a-day regimens in which the time of the middle dose varied.

RESULTS

In study I, the efficacy of the ascending treatment increased across the day, and in the afternoon it was equal to the efficacy of the twice-daily treatment, indicating that an initial bolus was not required for efficacy. The efficacy of the flat treatment declined across the day, and in the afternoon it was significantly less than in the twice-daily treatment, suggesting that tolerance may be developing. In study II, acute improvements in efficacy were reduced to the second of two closely spaced but not to two widely spaced bolus doses, suggesting that shortly after exposure to high concentrations, efficacy is reduced to given concentrations of methylphenidate. In a concentration-effect model, a tolerance term was needed to account for counterclockwise hysteresis.

CONCLUSIONS

Acute tolerance to methylphenidate appears to exist. This should be considered in the design of an optimal dosing regimen for the treatment of children with attention deficit hyperactivity disorder.

Phase-trafficking reagents and phase-switching strategies for parallel synthesis

Strategies for the parallel synthesis of small molecule arrays are reviewed with an emphasis on those approaches that integrate the sciences of organic synthesis and product purification. The use of phase-trafficking reagents (PTRs) and phase-switching strategies are highlighted, which allow the rapid, parallel synthesis of small molecule arrays with built-in purification determinants.

Scatter and attenuation measurements at distances greater than 10 cm from an 192Ir source

Most algorithms developed by various investigators for use in brachytherapy treatment planning have typically been designed to calculate the dose within a 10 cm range of a radiation source. These algorithms predict the dose well at distances < 10 cm from the source but were not developed and should not be utilized to predict the dose at distances > 10 cm. On the contrary, treatment planning systems and manual calculations will produce erroneous results when dose points > 10 cm are calculated using these algorithms. The spread in the data generated by the above algorithms is 16% at 15 cm and 42% at 20 cm. Physical measurements were performed at distances between 5 and 50 cm from a high activity 192Ir source in water. The measured data correlated well with the predicted data from 5 to 10 cm, which had a 5% spread. Beyond 10 cm the measured data fell central to the range of the predicted data, with the spread of the predicted data increasing from 5% to 80% with increasing distance from the source. The measured data was fitted with a model incorporating a buildup factor and an attenuation factor. The best fit values are in reasonable agreement with those obtained by two of the investigators, Thomason and Tripathi.

Polarization potentials causing pacemaker oversensing

Pacemaker oversensing with inappropriate inhibition is commonly caused by sensing of either T-waves or polarization potentials, which are difficult to distinguish from one another. Decisive evidence, obtained from telemetered electrograms and subthreshold pacing, is presented to support sensing of the polarization potential alone and the exclusion of the T-wave as the cause of oversensing in a patient.

A mixed resin bed for the quenching and purification of tetrabutylammonium fluoride mediated desilylating reactions

A polymer-bound calcium sulfonate resin is prepared and used to sequester tetrabutylammonium fluoride. The simultaneous use of the calcium sulfonate resin with a sulfonic acid resin is used for the quenching and purification of desilylating reactions involving tetrabutylammonium fluoride as the reagent. Employment of this resin workup technique eliminates the need for a liquid-phase extractive protocol allowing the procedure to be easily automated.

Five-year retention of the classically conditioned eyeblink response in young adult, middle-aged, and older humans

Human participants who 5 years earlier participated in studies of acquisition of the classically conditioned eyeblink response to a tone conditioned stimulus (CS) and an air puff unconditioned stimulus (UCS) returned to the laboratory to test for retention of the conditioned response (CR). Retention consisted of 20 tone CS-alone presentations. Young adult participants (23-31 years of age at the time of retention testing) showed good retention of the CR (45%), middle-aged participants (45-52 years) showed reduced retention (28%), and older participants (69-78 years) showed little evidence of retention (< 5%). Retention testing was followed by reacquisition of the CR in which the CS and the UCS were again paired. The ability to reacquire the CR also showed a decline with age. The data suggest that the CR can be retained over long intervals and that the degree of retention is age dependent.

Chemically-tagged Mitsunobu reagents for use in solution-phase chemical library synthesis

A general method for high-throughput product purification of Mitsunobu reactions is described. Tagged phosphine and azodicarboxylate reagents are used to synthesize individual library members in solution-phase. Workup and purification are easily accomplished by post-reaction sequestration of the tagged reagents and reagent byproducts by a complementary functionalized ion exchange resin. The reagents are utilized in a 3 step library synthesis.

Five-year retention of the classically conditioned eyeblink response in young adult, middle-aged, and older humans

Human participants who 5 years earlier participated in studies of acquisition of the classically conditioned eyeblink response to a tone conditioned stimulus (CS) and an air puff unconditioned stimulus (UCS) returned to the laboratory to test for retention of the conditioned response (CR). Retention consisted of 20 tone CS-alone presentations. Young adult participants (23-31 years of age at the time of retention testing) showed good retention of the CR (45%), middle-aged participants (45-52 years) showed reduced retention (28%), and older participants (69-78 years) showed little evidence of retention (< 5%). Retention testing was followed by reacquisition of the CR in which the CS and the UCS were again paired. The ability to reacquire the CR also showed a decline with age. The data suggest that the CR can be retained over long intervals and that the degree of retention is age dependent.

Objective and subjective measures of the pharmacodynamic effects of Adderall in the treatment of children with ADHD in a controlled laboratory classroom setting

In a randomized double-blind crossover study of children with attention deficit hyperactivity disorder (ADHD), the time course effects of four doses of Adderall (5, 10, 15, and 20 mg) and an inactive (placebo) control, and an active (Ritalin) control were evaluated. A laboratory classroom setting was established in which subjective (teacher ratings of deportment and attention) and objective (scores on math tests) measurements were taken every 1.5 hours across the day. In addition to significant time and dose effects of Adderall, significant time-of-day effects were documented in the placebo condition for the subjective measure of deportment and objective measures of performance. Regression analyses were used to estimate the magnitude of these baseline effects. Correlations across time were used to evaluate the test-retest reliability of each measure in the face of these time-dependent placebo effects. After placebo/time adjustments, within-subject correlations between pairs of measures were used to evaluate the validity of the math test as a measure of response to stimulant medication.

Analog classroom assessment of Adderall in children with ADHD

OBJECTIVE

This was a randomized, double-blind, crossover study of 30 children with attention-deficit/hyperactivity disorder (ADHD) that evaluated the time course effects of four doses of Adderall (5, 10, 15, and 20 mg), an inactive control (placebo), and a positive control (clinical dose of methylphenidate).

METHOD

For each treatment condition, a capsule was administered in the morning and assessments were performed in an analog classroom setting every 1.5 hours across the day. Subjective (teacher ratings of deportment and attention) and objective (scores on math tests) measures were obtained for each classroom session, and these measures were used to evaluate time-response and dose response effects of Adderall.

RESULTS

For doses of Adderall greater than 5 mg, significant time course effects were observed. Rapid improvements on teacher ratings and math performance were observed by 1.5 hours after administration, and these effects dissipated by the end of the day. The specific pattern of time course effects depended on dose: the time of peak effects and the duration of action increased with dose of Adderall.

CONCLUSIONS

This documentation of efficacy in a controlled study supports the addition of Adderall to the armamentarium of psychotropic medications for the treatment of ADHD. The differences in time-response patterns of Adderall and methylphenidate may help tailor treatment to meet specific clinical needs of different children with ADHD.

Recent advances in antiviral research: identification of inhibitors of the herpesvirus proteases

Major advances have been reported in the last two years regarding the molecular biology and structural properties of the herpesvirus proteases. X-ray diffraction studies have enabled several groups to solve the structure of the human cytomegalovirus protease. Fluorescence-based substrate assays have also been recently reported. These substrates exhibit sufficient kinetic and sensitivity properties to enable high-throughput screening efforts dedicated toward the discovery of protease inhibitors. Three classes of inhibitors have been reported recently: nonpeptidic aryl trifluoromethylketones; alternate substrate inhibitors (benzoxazinones/azalactones); and thiol-modifying inhibitors. The thiol-modifying class offers a unique opportunity to discover inhibitors specific to the human cytomegalovirus protease, as this protease requires reduced cysteine residues for its enzymatic activity.

The herpesvirus protease: mechanistic studies and discovery of inhibitors of the human cytomegalovirus protease

The herpesvirus protease is a recently identified enzyme which is essential for viral replication. It is found in all herpesviruses and offers a new molecular target for therapeutic intervention. Its genomic structure has recently been described and consists of a large open reading frame which encodes a fusion protein containing an amino-terminal protease domain in-frame with a carboxyl-terminal "assembly protein-like" domain. Auto-processing releases the amino-terminal protease as a maturational enzyme. The herpesvirus protease has been characterized as a novel serine protease. Four surface accessible sulfhydryl groups have been identified in the human cytomegalovirus (HCMV) protease. Utilizing a fluorogenic DABCYL-EDANS substrate assay, directed screening has identified a class of sulfhydryl-modifying benzimidazolylmethyl sulfoxides which inhibits recombinant HCMV protease. Site-directed mutagenesis studies suggest oxidative modification of surface-accessible HCMV protease Cys138 (and possibly Cys161) by this class of inhibitors. The benzimidazolylmethyl sulfoxide 1 inhibits HCMV protease (IC50 = 1.9 microM), exhibits selectivity vs. mammalian serine proteases, and exhibits antiviral activity in an HCMV infected cell culture assay.

Behavioral effects and receptor binding affinities of fentanyl derivatives in rhesus monkeys

These studies examined the opioid receptor binding affinities and behavioral effects of several fentanyl derivatives in rhesus monkeys. OHM3295, OHM3296, OHM3326 and OHM3463 displayed high affinity for mu (IC50 = 7-66 nM) as compared to kappa (IC50 = 263-3255 nM) or delta (IC50 = 480-4500 nM) receptors as measured by their ability to displace [3H](D-Ala2-Me-Phe4,Glyol5)enkephalin, [3H](5,7,8[beta])-N-[2- (1-pyrrolidinyl)1-oxaspiro[4,5]dec-8-yl]benzeneacetamide and [3H](D-Pen2-D-Pen5)enkephalin, respectively. All four compounds maintained i.v. self-administration responding at rates above those maintained by the mu agonist alfentanil. In drug discrimination studies, OHM3463, OHM3326 and OHM3296 substituted completely for nalbuphine whereas OHM3295, and a related compound, mirfentanil, substituted partially for nalbuphine. In morphine-treated monkeys, OHM3295 substituted for naltrexone; in monkeys acutely deprived of morphine, only OHM3463 reversed naltrexone-lever responding. All four compounds had antinociceptive effects, although the extent to which these effects were accompanied by respiratory depression or modified by naltrexone, as well as the interactions between antinociceptive effects of fentanyl derivatives and alfentanil, varied markedly among compounds. Thus, OHM3463 shared effects with mu agonists (e.g., alfentanil) under all conditions; the other three compounds had opioid agonist effects under only a subset of conditions. Moreover, one of these compounds (OHM3295) antagonized the discriminative stimulus and antinociceptive effects of other mu agonists. Collectively, these compounds appear to vary on two dimensions: opioid efficacy and the contribution of nonopioid actions to their antinociceptive effects. Together with results obtained with other fentanyl derivatives (mirfentanil) under similar conditions, results of the current study suggest this chemical class might be especially fertile for the development of novel analgesics that might have reduced toxicity and abuse liability as compared to fentanyl and related compounds that are currently used in medicine.

Magnetic brain stimulation: safety studies

We describe short-term and long-term safety studies after low repetition rate magnetic brain stimulation in 10 normal subjects. We obtained quantitative EEG data, psychometric test results, serum prolactin and cortisol levels before and after brain stimulation. EEG and psychometric data were also obtained in 5 of these subjects 16-24 months after the initial experiment. Short- and long-term studies did not show any deleterious effects. Randt delayed recalls, however, showed a transient reduction in the score immediately after stimulation which resolved on retesting in 2 weeks. To address the question of fatigue we repeated Randt tests in 4 subjects before and after magnetic brain stimulation but without the other extensive psychometric, EEG and blood tests. Pre- and post-stimulation scores on this occasion showed no significant difference in these 4 subjects suggesting that the transient changes in the previous Randt score were related to fatigue. We conclude that single-pulse magnetic brain stimulation has no deleterious effects after magnetic brain stimulation.

Serotonin 5-HT3 antagonists fail to affect ethanol self-administration of rats

Five Long-Evans hooded rats were trained to lever press according to fixed-ratio 5 reinforcement schedules for 0.06 ml dipper deliveries of 8% w/v ethanol during daily (M-F) 0.5-h experimental sessions. After ethanol self-administration was established, doses of the serotonin 5-HT3 antagonists, ondansetron (0.03-3.0 mg/kg), granisetron (0.01-1.0 mg/kg), and SC-51296 (0.1-10.0 mg/kg) were administered prior to ethanol sessions to determine their effects on ethanol self-administration. None of the doses of the antagonists had significant effects on numbers of obtained ethanol deliveries. Subsequently, each antagonist (ondansetron, 0.1 mg/kg; granisetron, 0.3 mg/kg; SC-51296, 0.1 mg/kg) was administered b.i.d. for five consecutive daily sessions. During none of these chronic tests with the 5-HT3 antagonists were there significant main effects of drug administration. Overall, these results do not support the hypothesis that the serotonin 5-HT3 antagonists would have robust therapeutic efficacy in the treatment of alcoholism.