A randomized controlled trial of the effect of sublingual orally disintegrating olanzapine versus oral olanzapine on body mass index: the PLATYPUS Study

BACKGROUND

Patients with schizophrenia and bipolar disorder have frequently reported weight gain during olanzapine treatment. Previous studies have observed a decrease in weight gain, or weight loss, in patients switching from standard olanzapine tablets (SOT) to orally disintegrating olanzapine (ODO) tablets. The primary objective of this study was to investigate the change in body mass index (BMI) in patients who had previously gained weight with SOT and continued with this therapy during the study period, compared with those patients who switched to ODO during the study period.

METHODS

This was a 16-week, multicentre, randomized, double-blind, double-dummy, study of outpatients diagnosed with schizophrenia, schizoaffective disorder, related psychotic disorder or bipolar disorder, who were taking 5-20 mg SOT daily. Patients continued treatment with 5-20 mg olanzapine in a flexible single daily dose, and were randomized to either receive sublingual ODO plus an oral placebo, or sublingual placebo plus SOT.

RESULTS

No statistically significant between group differences in mean change from baseline in BMI, weight or waist circumference were observed. Analysis of change in body weight from baseline, by pre-specified category (no change, loss of >or=1.5 kg, gain of >or=1.5 kg), revealed a significant difference between groups, favoring ODO patients, who also experienced a significant reduction in subjective appetite and better treatment compliance, compared to patients in the SOT group.

CONCLUSIONS

In this study, patients treated with ODO experienced a similar mean change in BMI and weight from baseline, to those patients treated with SOT.

Olanzapine vs haloperidol in geriatric schizophrenia: analysis of data from a double-blind controlled trial

OBJECTIVES

To compare the six-week clinical response and safety profile of schizophrenia patients, age > or =60 years, receiving olanzapine (OLZ) vs haloperidol (HAL) in a double blind, randomized trial.

METHODS

Double-blind data on patients age > or =60 randomized to 5 mg/d OLZ (n=83) or 5 mg/d HAL (n=34) (Week 1) then flexibly dosed to 5-20 mg/d over six weeks, with a 48-week extension for responders, were analyzed post-hoc. Efficacy indices included the PANSS Total and PANSS Psychosis Core Total (PPCT). Safety measures included the Simpson-Angus Scale (SAS), Barnes Akathisia Scale (BAS), Abnormal Involuntary Movement Scale (AIMS), treatment-emergent adverse events, and laboratory values. Mixed model, repeated measures (MMRM) analyses were applied to all continuous data measured at each visit. Continuous data recorded only at phase completion or termination were analyzed with a fixed effect last observation carried forward (LOCF) model. Frequencies of categorical response data were analyzed using Fisher's exact methods. Differences were tested for significance at Week 6 using a two-sided alpha value of 0.05.

RESULTS

HAL group (n=34; age range 60-80) received a mean modal dose 9.4 mg/d while OLZ group (n=83; age range 60-86) received a mean modal dose 11.9 mg/d. At Week 6, OLZ was superior to HAL on both the PANSS Total (p=0.015) and PPCT (p=0.043). Considering safety, OLZ was superior to HAL for the SAS and BAS (p<0.001; p<0.001). No spontaneous adverse event occurred more frequently with OLZ than with HAL. In patients never receiving adjunct anticholinergic therapy, no significant differences were present for anticholinergic-like side effects including blurred vision, dry mouth, constipation, or urinary difficulties.

CONCLUSIONS

In elderly schizophrenia patients, olanzapine was more efficacious and better tolerated for extrapyramidal signs than was haloperidol. Olanzapine was equivalent to haloperidol for anticholinergic-like side effects when corrected for anticholingergic agents.

Are there any clinical indications for measuring IgG subclasses?

It is questionable as to whether a low serum concentration of one of the IgG subclasses identifies a disease state. A low IgG(1) concentration is found in primary or secondary immunodeficiency states but does not occur in isolation. Low IgG(2) concentration is associated with an increased risk of bacterial infections but only in some individuals and not in others. Isolated IgG(3) and IgG(4) deficiency have not been convincingly demonstrated. Therefore, the isolated finding of low concentrations of one or more IgG subclass does not identify individuals at risk. In contrast, the finding of low serum concentrations of antibodies to specific bacterial antigens (Haemophilus influenzae type B, pneumococcus, tetanus and diphtheria) does identify individuals at risk and these measurements should be used in preference to IgG subclass measurement.

Computerized measurement of cognitive impairment and associated neuropsychiatric dimensions

This study aimed to cross-validate the capacity of a computer software program to detect and measure, using a measurement method applied to the content and form analysis of 5-minute speech samples, cognitive impairment and associated comorbid neuropsychiatric psychobiological dimensions in drug-abusing patients. At the University of California-Irvine (UCI) Neuropsychiatric Center, 28 drug-abusing inpatients using illegal drugs were clinically evaluated. Their scores for cognitive impairment derived by the computerized content analysis method were compared with scores derived from selected tests from the Halstead-Reitan Neuropsychological Test Battery, the computerized Automated Neuropsychological Assessment Metric Battery (ANAM), the Alzheimer's Disease Assessment Scale-Cognitive Portion, the Stroop Color and Word Test, the Symbol Digit Modalities Test, and the Controlled Oral Word Association Test. The statistical significance (P value) of the correlations of scores from these different measures with scores obtained from the computerized content analysis measures was less than .05 to .001. The comparative "hit rate," detecting cognitive impairment above the norms for each measure administered to these drug-abusing patients, for the computerized content analysis measures and some of the ANAM neuropsychological measures was 75% to 89%, and for the other neuropsychological measures, 25% to 64%. In conclusion, the computerized content analysis methodology applied to 5-minute verbal samples is a valid, rapid, easily administered measurement instrument for assessing the magnitude of cognitive impairment and comorbid neuropsychiatric dimensions.

Risperidone for the treatment of stuttering

A randomized, double-blind, placebo-controlled study was conducted to assess the efficacy of risperidone in the treatment of developmental stuttering in 16 adults. Eight subjects received placebo and eight received risperidone at 0.5 mg once daily at night, increased to a maximum of 2 mg/day. After 6 weeks of treatment, decreases in all measures of stuttering severity were greater in the risperidone group than in the placebo group; the between-treatment difference was significant (p < 0.05) on the most important measure, the percentage of syllables stuttered. In the risperidone group, reductions from baseline in scores for the percentage of syllables stuttered, time stuttering as a percentage of total time speaking, and overall stuttering severity were significant (p < 0.01); changes in scores on the fourth measure of stuttering, duration, were not significant. No significant decreases occurred in the placebo group. Among the eight patients in the risperidone group, five responded best to 0.5 mg/day, with stuttering recurring at higher doses. The remaining three patients responded better with increasing doses of risperidone. Risperidone was generally well tolerated. The results of this small study indicate that risperidone may be effective in the treatment of developmental stuttering. This finding needs to be confirmed in a larger trial.

Management of child and adolescent stuttering with olanzapine: three case reports

Vast arrays of medications have been used, with limited success, to manage stuttering. Haloperidol and risperidone are the only two medications that have shown efficacy via double-blind studies in controlling stuttering symptoms. We present the first case reports of olanzapine in the management of stuttering. Three case histories are presented: a 10-year-old boy, a 16-year-old male adolescent with developmental stuttering, and a 9-year-old boy with medication-induced stuttering whose symptoms are successfully controlled with olanzapine. These case studies suggest that olanzapine may be a pharmacologic option in the management of stuttering.

Stuttering: neuropsychiatric features measured by content analysis of speech and the effect of risperidone on stuttering severity

Positron-emission tomographic (PET) studies and genetic research of stuttering have recently revealed underlying cerebral neurobiologic contributing factors in this disorder. We aimed to assess whether cognitive impairment and other neuropsychiatric dimensions could be detected through computerized content analysis of short samples of speech from stutterers, and whether administration of risperidone in a double-blind placebo-controlled study could decrease the severity of stuttering, as well as any of the neuropsychiatric features of these stutterers. A group of 21 stutterers with the developmental form of stuttering, an onset before age of 6 years, aged 20 to 74 years, and who were otherwise free of major medical or psychiatric problems, initially gave a 5-minute tape-recorded speech sample in response to purposely ambiguous instructions to talk about any interesting or dramatic life experiences. Then, half of these subjects (n = 10) were randomly selected to receive 6 weeks of risperidone treatment up to 2.0 mg/d and the other half (n = 11) were administered a placebo. Both groups of subjects gave a second verbal sample after 6 weeks of treatment. Significantly elevated cognitive impairment and social alienation-personal disorganization scores, derived from the computerized content of the initial 5-minute speech samples, were found. After 6 weeks, the risperidone group improved significantly on a measure of severity of stuttering but did not improve on the percentage of time spent stuttering. The placebo group did not improve on either measure of stuttering. The psychopathological processes of subjects who received risperidone treatment, including those with elevated cognitive impairment and social alienation-personal disorganization, did not change significantly. However, stutterers who had lower scores on verbal content analysis-derived shame anxiety, guilt anxiety, or hostility inward measures improved significantly more with risperidone than stutterers with higher scores on these measures. The findings of elevated cognitive impairment and social alienation-personal disorganization scores of adult stutterers with the early developmental form of stuttering are consistent with the neurobiologic abnormalities found in PET-scan and genetic research involving stutterers. Risperidone (< or =2.0 mg/d) can reduce the severity of stuttering while not significantly affecting the magnitude of neuropsychiatric dimensions such as cognitive impairment or social alienation-personal disorganization. The less the inward shame, guilt, or hostility of the stutterers, the better the beneficial effect of risperidone on the severity of stuttering.

Which patients with prostatic carcinoma require a staging bone scan?

OBJECTIVE

To determine whether the level of prostate-specific antigen (PSA) can be used to decide which patients with newly diagnosed prostatic carcinoma require a staging bone scan.

PATIENTS AND METHODS

Of patients referred during an 18-month period for a staging bone scan, 98 (median age 72 years, range 52-89) had had their serum PSA level determined within 4 weeks of the bone scan and were assessed retrospectively for the presence of bony metastases.

RESULTS

Of the 98 patients, 26 who had bone scans showing bony metastases had a PSA level > 40 ng/mL. Reviewing the other published studies showed that in those newly diagnosed patients with a PSA level of < 20 ng/mL, the probability of having bony metastases detected on a bone scan was < 1%.

CONCLUSIONS

A staging bone scan can be omitted in the vast majority of patients with newly diagnosed prostatic carcinoma and a PSA level < 20 ng/mL.

Glycosyl phosphatidyl inositol phospholipase D activity in human serum

We measured serum glycosyl phosphatidyl inositol phospholipase D (GPI-PLD) by its alkaline phosphatase releasing activity in healthy and diseased individuals. Linearity with respect to serum concentration was obtained only with very low serum volumes (below about 0.2 microL) necessitating a large predilution of serum to avoid potential artefacts. The assay was sufficiently precise for routine use. Patients with liver disease had lower activities and those with renal disease had higher activities than healthy controls. Following liver transplantation there was no correlation between GPI-PLD and conventional markers of liver function but there was a marked correlation with cholesterol concentration. These observations suggest that liver is a major source of GPI-PLD in serum. Its function remains unknown.

A novel capillary collection method for obtaining current glycosylated haemoglobin levels in diabetic children

A simple method for collecting capillary blood for measurement of glycosylated haemoglobin (HbA1c) was developed that allows samples to be obtained at home and then mailed to the laboratory 2 weeks before a hospital visit. A single drop of blood is collected into a 2 ml plastic tube and sent for HbA1c assay on the Diamat HPLC system which has inter- and intra-assay coefficients of variation < 2.6 and < 1.2%, respectively. Results of simultaneously obtained venous and capillary samples in 32 diabetic children agreed well with each other. A separate study of 25 patients was performed to determine whether transport conditions affected the samples. Posted samples were compared with venous samples; again the values were in good agreement. This method is now used routinely in the diabetic clinic. Its value was determined by questionnaire in 40 children with age range 4-17 years. No family experienced difficulty collecting samples and all samples received were suitable for analysis. Children preferred this method to blood collection in the clinic as they felt it was less traumatic and more convenient. Seventy-nine percent of them understood its value in the long-term control of diabetes. In 40.5% of visits changes to management were made at the clinic due to the availability of the results.

Investigation of the use of impermeable fluid barriers between pelleted and supernatant enzyme activity in a pseudohomogeneous enzyme immunoassay

We have investigated the feasibility of performing an automated pseudohomogeneous enzyme immunoassay in which a separation step is not apparent to the user. This was achieved using a layer of silicone fluid, which is immiscible with aqueous solutions, as a physical barrier between the pelleted and supernatant enzyme. Initially we produced a manual assay based on the Serozyme T4 assay to demonstrate the feasibility of the approach. This assay showed good precision, parallelism and correlated with 'in house' results on patients' samples. Production of a fully automated assay was made difficult by the design of available equipment but none the less we demonstrated the feasibility of the automated approach by producing a standard curve for T4.

A kinetic assay for urea in undiluted urine specimens

We describe a kinetic assay for quantifying urea in undiluted urine samples. The assay linearity extends to urea concentrations of 400 mmol/L, is free from interference from blood (10 mL/L) or bilirubin (1 mmol/L), is sufficiently precise for routine use, and correlates well with an established method for assay of diluted urine samples.

A kinetic assay for urea in undiluted urine specimens

We describe a kinetic assay for quantifying urea in undiluted urine samples. The assay linearity extends to urea concentrations of 400 mmol/L, is free from interference from blood (10 mL/L) or bilirubin (1 mmol/L), is sufficiently precise for routine use, and correlates well with an established method for assay of diluted urine samples.

An immunoprecipitation assay for high molecular weight alkaline phosphatase in human serum

The serum of patients with obstructive liver disease may contain a high molecular weight form of alkaline phosphatase (high Mr alkaline phosphatase). The presence of this form of alkaline phosphatase is associated with hepatic malignancies. We have investigated the use of anti-alkaline phosphatase monoclonal antibodies which do not bind high Mr alkaline phosphatase in assays for high Mr alkaline phosphatase. Direct immunoprecipitation of liver and bone alkaline phosphatase with solid phase anti-liver alkaline phosphatase antibody (which also reacts with bone alkaline phosphatase) and measurement of the residual supernatant alkaline phosphatase activity led to a precise assay. Intestinal alkaline phosphatase interfered in this assay which, consequently, was of little use in the differential diagnosis of liver disease. Indirect precipitation of liver, bone, placental and intestinal alkaline phosphatase by soluble anti-liver alkaline phosphatase (which reacts with liver and bone alkaline phosphatases), soluble anti-intestinal alkaline phosphatase (which reacts with placental and intestinal alkaline phosphatases) and solid phase anti-mouse IgG led to an assay which, although less precise, showed more promise of being useful clinically.

Investigation of the use of bilirubin oxidase to measure the apparent unbound bilirubin concentration in human plasma

An investigation into the use of bilirubin oxidase to measure the apparent concentration of unbound bilirubin in solutions of bilirubin or bilirubin/human serum albumin demonstrated (1) near linearity of oxidation rate with bilirubin concentration up to 16 mumol/L, (2) linearity with respect to enzyme concentration up to 75 mg/L, (3) specificity of the enzyme for unbound bilirubin, as opposed to bound bilirubin, (4) poor precision. Very small absorbance changes leading to poor precision and the potential for interference by conjugated bilirubin meant that the method was unsuitable for patient samples.

The preparation of monoclonal antibodies to human bone and liver alkaline phosphatase and their use in immunoaffinity purification and in studying these enzymes when present in serum

1. Liver and bone alkaline phosphatase isoenzymes were solubilized with the zwitterionic detergent sulphobetaine 14, and purified to homogeneity by using a monoclonal antibody previously raised against a partially-purified preparation of the liver isoenzyme. Both purified isoenzymes had a specific activity in the range 1100-1400 mumol/min per mg of protein with a subunit Mr of 80,000 determined by SDS/polyacrylamide gel electrophoresis. Butanol extraction instead of detergent solubilization, before immunoaffinity purification of the liver enzyme, resulted in the same specific activity and subunit Mr. The native Mr of the sulphobetaine 14-solubilized enzyme was consistent with the enzyme being a dimer of two identical subunits and was higher than that of the butanol-extracted enzyme, presumably due to the binding of the detergent micelle. 2. Pure bone and liver alkaline phosphatase were used to raise further antibodies to the two isoenzymes. Altogether, 27 antibody-producing cell lines were cloned from 12 mice. Several of these antibodies showed a greater than 2-fold preference for bone alkaline phosphatase in the binding assay used for screening. No antibodies showing a preference for liver alkaline phosphatase were successfully cloned. None of the antibodies showed significant cross-reaction with placental or intestinal alkaline phosphatase. Epitope analysis of the 27 antibodies using liver alkaline phosphatase as antigen gave rise to six groupings, with four antibodies unclassified. The six major epitope groups were also observed using bone alkaline phosphatase as antigen. 3. Serum from patients with cholestasis contains soluble and particulate forms of alkaline phosphatase. The soluble serum enzyme had the same size and charge as butanol-extracted liver enzyme on native polyacrylamide-gel electrophoresis. Cellulose acetate electrophoresis separated the soluble and particulate serum alkaline phosphatases as slow- and fast-moving forms respectively. In the presence of sulphobetaine 14 all the serum enzyme migrated as the slow-moving form on cellulose acetate electrophoresis. Monoclonal anti-(alkaline phosphatase) immunoadsorbents did not bind the particulate form of alkaline phosphatase in cholestatic serum but bound the soluble form. In the presence of sulphobetaine 14 all the cholestatic serum alkaline phosphatase bound to the immunoadsorbents. 4. The electrophoretic and immunological data are consistent with both particulate and soluble forms of alkaline phosphatase in cholestatic serum being derived from the hepatocyte membrane.

Bromcresol purple method for serum albumin gives falsely low values in patients with renal insufficiency

In patients with renal insufficiency, the BCP method underestimated the serum albumin. In non-renal patients, the BCP method gave albumin results in good agreement with the immunological method. The underestimation did not appear to be related to the degree of renal impairment. The interferent appears to act by preventing the binding of BCP to albumin. The BCG method is much less susceptible to this interference.

Elimination of the "chromogen oxidase" activity of bilirubin oxidase added to obviate bilirubin interference in hydrogen peroxide/peroxidase detecting systems

The use of bilirubin oxidase to remove interference by bilirubin in hydrogen peroxide/peroxidase detecting systems is hampered by its inherent "chromogen oxidase" activity (its ability to oxidize the chromogens used in the systems). This unwanted activity is greater than 99% inhibited by 0.5 mmol/L cyanide, 97% inhibited by 20 mmol/L azide. At these same concentrations, they inhibit bilirubin oxidase activity by 95% and 73%, respectively. Sequential addition of reagents allows the use of bilirubin oxidase without interference by the chromogen oxidase activity.

Elimination of the "chromogen oxidase" activity of bilirubin oxidase added to obviate bilirubin interference in hydrogen peroxide/peroxidase detecting systems

The use of bilirubin oxidase to remove interference by bilirubin in hydrogen peroxide/peroxidase detecting systems is hampered by its inherent "chromogen oxidase" activity (its ability to oxidize the chromogens used in the systems). This unwanted activity is greater than 99% inhibited by 0.5 mmol/L cyanide, 97% inhibited by 20 mmol/L azide. At these same concentrations, they inhibit bilirubin oxidase activity by 95% and 73%, respectively. Sequential addition of reagents allows the use of bilirubin oxidase without interference by the chromogen oxidase activity.

A continuous monitoring spectrophotometric method for the measurement of angiotensin-converting enzyme in human serum

A continuous monitoring spectrophotometric method for the measurement of angiotensin-converting enzyme in human serum is described. It is based on the hydrolysis of furylacrylylphenylalanylglycylglycine and applied to an IL Multistat III centrifugal analyser. The method offers better precision and freedom from interference than a fluorimetric assay we have previously described.

The presence and orientation of ecto-5'-nucleotidase in rat liver lysosomes

Purified rat liver lysosomes contained 5'-nucleotidase activity which was 92 +/- 2% [4]latent. This latency was lost in response to a permeant sugar at a similar rate to that of the lysosomal marker enzyme beta-N-acetylglucosaminidase indicating that the 5'-nucleotidase was genuinely located in the lysosome and not a plasma membrane contaminant. Lysosomal 5'-nucleotidase exhibited the following properties characteristic of ecto-5'-nucleotidase inhibition by specific polyclonal antibodies: binding to a monoclonal antibody; inhibition by 1 mmol/1 alpha beta-methylene ADP; immunoreactive subunits of 70 and 38 kDa. Lysosomes in addition contained immunoreactive species of intermediate molecular mass.

A kinetic fluorimetric assay for the measurement of angiotensin-converting enzyme in human serum

The development and assay performance of a direct kinetic fluorimetric assay for angiotensin-converting enzyme is described. It is based on the substrate developed by Carmel et al. (Clin Chim Acta 1979; 93: 215-20), and applied to a microcentrifugal analyser with fluorescence optics. The method is sufficiently sensitive and precise to detect both normal and pathological activities; the method is linear up to at least three times the upper limit of the reference range. The method correlates well with an established method. Because of interference, the method is unsuitable for use with icteric or haemolysed samples.

Evidence for interference by ascorbate in the measurement of cerebrospinal fluid glucose by a kinetic glucose oxidase/peroxidase procedure

Glucose in the cerebrospinal fluid (CSF) of neonates, as measured with a kinetic glucose oxidase/peroxidase procedure, was sometimes very low. When these samples were stored at 4 degrees C and subsequently re-analyzed, or if the samples were analyzed at any time after receipt by using a glucose dehydrogenase assay, the values were much higher. We found that the discrepancies in the values were caused by a lag phase in the kinetic method, during which no color developed. Because the lag phase exceeds the time over which the reaction is monitored in the kinetic procedure, this leads to the erroneously low values. The interference could be reproduced experimentally by adding ascorbic acid to CSF or plasma samples, or removed by adding ascorbate oxidase to CSF samples. Plasma glucose, as estimated by the kinetic glucose oxidase method, showed no such interference.

Evidence for interference by ascorbate in the measurement of cerebrospinal fluid glucose by a kinetic glucose oxidase/peroxidase procedure

Glucose in the cerebrospinal fluid (CSF) of neonates, as measured with a kinetic glucose oxidase/peroxidase procedure, was sometimes very low. When these samples were stored at 4 degrees C and subsequently re-analyzed, or if the samples were analyzed at any time after receipt by using a glucose dehydrogenase assay, the values were much higher. We found that the discrepancies in the values were caused by a lag phase in the kinetic method, during which no color developed. Because the lag phase exceeds the time over which the reaction is monitored in the kinetic procedure, this leads to the erroneously low values. The interference could be reproduced experimentally by adding ascorbic acid to CSF or plasma samples, or removed by adding ascorbate oxidase to CSF samples. Plasma glucose, as estimated by the kinetic glucose oxidase method, showed no such interference.

Sugar transport in rat liver lysosomes. Direct demonstration by using labelled sugars

Purified rat liver lysosomes ('tritosomes') were prepared from rats injected with Triton WR-1339. 2. The water space of tritosomes, measured by using [3H]water and [14C]sucrose, was 2.15 +/- 0.72 microliter/mg of protein (mean +/- S.E.M., n = 12). 3. Tritosomes, when compared with a crude preparation of normal lysosomes by an indirect method of study, showed sugar specificity but decreased stereospecificity of sugar uptake. 4. At 125 mM the relative rates of net uptake of D-[14C]ribose, D-[14C]- or D-[3H]glucose and 2-deoxy-D-[3H]glucose were the same as that inferred from the indirect study. 5. The entry of D-[3H]glucose into tritosomes showed concentration-dependence suggestive of saturation, with a Km of 48 +/- 18 mM (4). 6. D- and L-glucose, D-ribose, 2-deoxy-D-glucose and D-mannose competed with D-[14C]glucose or D-[14C]ribose for uptake. 7. Cytochalasin B inhibited D-[3H]glucose uptake. 8. Uptake of 1 mM-L-[14C]glucose was slower than for 1 mM-D-[14C]glucose. 9. It is concluded that a facilitated-diffusion transport system is present in purified rat liver lysosomes.

Volunteer program to assist the elderly to remain in home settings

A community-based volunteer program was organized to improve the quality of life for elderly individuals in the community. Each elderly client referred for the program from welfare and home health agencies, or from family and friends, was matched with a volunteer who visited regularly. The volunteers also assisted with transportation, sitting, home maintenance, and meal preparation when these services were not available. The goals of the program were to improve the quality of life of elderly in the community, to assist the clients to remain in their home setting despite physical limitations, to encourage positive attitudes toward the elderly by the volunteers, and to increase the community's awareness of the older person's needs. The program also included educational seminars on gerontology for volunteers and community members.