Pharmacologic treatment of anxiety disorders in Parkinson disease

OBJECTIVE

Neither best practices nor an evidence base for the pharmacologic treatment of anxiety in Parkinson disease (PD) has been established. This study investigated pharmacologic treatment of anxiety disorders in idiopathic PD and the associated clinical features.

DESIGN

Cross-sectional.

SETTING

Three community-based movement disorder neurology practices.

PARTICIPANTS

250 subjects with PD.

MEASUREMENTS

Anxiety disorder diagnoses were established by consensus using a panel of six psychiatrists with expertise in geriatric psychiatry and movement disorders. Current medications were provided by the treating neurologists at the time of interview.

RESULTS

Among subjects with anxiety disorders only, 53% were untreated with medications. When anxious subjects with comorbid depressive disorders were included, 70.8% were on medications effective for treatment of anxiety. Subjects with anxiety and comorbid depressive disorders were more likely to be treated for their psychiatric disturbances than subjects with anxiety disorders alone (odds ratio: 8.33), as were subjects with comorbid motor fluctuations (odds ratio: 3.65). There were no differences in the types of anti-anxiety medications used in regard to the presence of depression or motor fluctuations.

CONCLUSIONS

These findings suggest that over half of nondepressed PD patients with clinically significant anxiety are untreated with medication. A better understanding of the role of clinical features associated with anxiety in PD, such as depression and motor fluctuations, may improve the recognition and treatment of anxiety disorders in this population.

Anxiety and self-perceived health status in Parkinson's disease

Both anxiety and depression are associated with lower self-perceived health status (HS) in persons with Parkinson's disease (PD). Given the high co-morbidity with depression and other non-motor symptoms, it is unclear whether anxiety disorders, in general, versus specific anxiety subtypes have an independent effect on HS in PD. To examine this question, comprehensive assessments of motor and non-motor symptoms from 249 subjects with idiopathic PD followed in three community-based movement disorders neurology practices were analyzed. HS was measured using the 8-item PD Questionnaire (PDQ-8). Psychiatric diagnoses were established by consensus using a panel of six psychiatrists with expertise in geriatric psychiatry and movement disorders. Stepwise multiple regression analyses were used, with the PDQ-8 score as the dependent variable, to identify independent predictors of HS among motor, psychiatric, and other non-motor variables. Among the anxiety disorders, only anxiety associated with motor fluctuations was an independent predictor of HS after accounting for co-morbid depression and other clinical features. In addition, depressive disorders were also an independent predictor of lower HS. Prevention or treatment of state-dependent anxiety may improve HS in persons with PD.

Prevalence of anxiety disorders and anxiety subtypes in patients with Parkinson's disease

Anxiety disorders are common in Parkinson's disease (PD), but are not well characterized. This study determined the prevalence and clinical correlates of all DSM-IV-TR anxiety disorder diagnoses in a sample of 127 subjects with idiopathic PD who underwent comprehensive assessments administered by a psychiatrist and neurologist. A panel of six psychiatrists with expertise in geriatric psychiatry and/or movement disorders established by consensus all psychiatric diagnoses. Current and lifetime prevalence of at least one anxiety disorder diagnosis was 43% (n = 55) and 49% (n = 63), respectively. Anxiety disorder not otherwise specified, a DSM diagnosis used for anxiety disturbances not meeting criteria for defined subtypes, was the most common diagnosis (30% lifetime prevalence, n = 38). Compared with nonanxious subjects, panic disorder (n = 13) was associated with earlier age of PD onset [50.3 (12.2) vs. 61.0 (13.7) years, P < 0.01], higher rates of motor fluctuations [77% (10/13) vs. 39% (25/64), P = 0.01] and morning dystonia [38% (5/13) vs. 13% (8/62), P < 0.03]. This high prevalence of anxiety disorders, including disturbances often not meeting conventional diagnostic criteria, suggests that anxiety in PD is likely underdiagnosed and undertreated and refined characterization of anxiety disorders in PD is needed. In addition, certain anxiety subtypes may be clinically useful markers associated with disease impact in PD.

Use of Guideline Recommended Follow-Up Care in Cancer Survivors

BACKGROUND

After potentially curative cancer treatment, patients may receive procedures for routine monitoring for recurrence or for evaluation of symptoms or signs.

OBJECTIVE

We sought to characterize surveillance care guideline-recommended and other procedures performed in cancer survivors according to routine versus diagnostic indications.

METHODS

This was a retrospective cohort study of paper and electronic medical records between 1990 and 2000 from a large midwestern U.S. integrated health care delivery system of 500 patients who received curative treatment of breast, colorectal, endometrial, lung, or prostate cancer. Our measures were the indications for potential surveillance procedures as recommended by clinical practice guidelines or otherwise.

RESULTS

Among 14,670 procedures of interest received, 82.0% were performed for routine surveillance, whereas 10.6% were performed for diagnostic indications and 7.3% had indeterminate indications. Office visits most were often delivered for routine indications (91.6%), followed by guideline recommended tests for local recurrence (range 74.1-98.4%, depending on the specific test and cancer). In general, tests that were not recommended in established guidelines were for the purposes of detection of metastatic recurrence and were less often delivered for routine indications (overall frequency 59.2%, P<0.0001 compared with recommended testing).

CONCLUSION

Office visits and testing for local recurrence of cancer generally are performed for routine surveillance, regardless of recommendation by practice guidelines. Because procedures not recommended by practice guidelines were more often for diagnostic purposes, classification of patients as undergoing intensive surveillance may be misleading and may require record review to confirm.

Capsaicin-induced inactivation of sensory neurons promotes a more aggressive gene expression phenotype in breast cancer cells

Capsaicin-induced inactivation of sensory neurons has been reported to enhance metastasis of a murine breast cancer cell line, specifically enhancing myocardial metastases. Here we characterized changes in gene expression patterns in primary tumors which developed in capsaicin-treated vs. control mice. We identified a small cohort of genes (17) which all showed significant decreases in expression levels. All of the identified genes have been linked to cell growth, differentiation, and/or cancer progression. Three representative genes, Caspase-7 (an executor of apoptosis), ADAM-10 (A Disintegrin and Metalloprotease), and Elk-3 (a transcriptional repressor of the ternary factor subfamily of the Ets factors) were further investigated. All three showed dramatic downregulation at the protein level in primary tumors from capsaicin-treated animals compared with control (vehicle-treated) animals, and their expression was also lost in cell culture. Elk-3 and Caspase-7 were not expressed in vitro in cultured cell lines, suggesting that their expression was induced by the tumor microenvironment. Loss of Caspase-7 expression can be expected to result in loss of function of apoptotic pathways. At first glance, loss of ADAM-10 expression would be expected to result in decreased invasive capability, due to loss of matrix metalloprotease activity. However, just the opposite appears to be true. We found that ADAM-10 actually hydrolyzes Substance P. Specifically ADAM-10 produces the same growth-inhibitory products from Substance P (i.e., SP (1-7)) that Neprilysin does, so that loss of ADAM-10 expression actually results in loss of production of growth inhibitory peptides from Substance P. Similarly, ADAM-10 also efficiently hydrolyzes Calcitonin Gene-Related Peptide, which may act in concert with Substance P. Finally, overactivity of Ets transcriptional suppressor functions has been linked to inhibition of tumorigenesis (e.g., Erf and Mef), and in addition loss of Elk-3 expression might also be be linked to tumorigenesis via loss of its putative anti-inflammatory activities. There is anecdotal evidence in the literature to indicate that the rest of the down-regulated genes may also contribute to development of a more aggressive phenotype in this breast cancer model.

Effectiveness of a home-based exercise intervention for HIV-infected adults: a randomized trial

The authors conducted a randomized controlled trial to assess the impact of a 15-week (20 minutes three times per week) home-based aerobic exercise intervention versus usual care on the physical endurance, immune status, and self-reported health status of 99 HIV-infected adults. In the exercise group, there was no improvement in physical endurance or health-related quality of life (HRQOL), except in the Medical Outcomes Study-HIV Health Survey Overall Health subscale (difference = 12.1, 95% confidence interval = 2.0-22.2, p = .02). Although physical endurance levels were maintained at baseline levels in the intervention group and declined in the control group, differences between the groups were small and not significant. There were also no significant changes in CD4+ T-lymphocyte counts. Exercise appears to be safe in HIV-infected patients. Improvements in physical endurance and HRQOL might result if the exercise protocol is longer or progressive. Further research is needed to establish guidelines for exercise in patients on highly active antiretroviral therapy.

Use of short-term assays to evaluate the potential toxicity of two new biosoluble glasswool fibers

Two new glasswools were developed for optimal biosolubility in the lung: JM 902, for insulation and filtration; and JM 901F, for standard thermal and acoustical insulation. Both were tested for lung biopersistence and their potential to induce persistent pulmonary inflammation in rats. Their dissolution rate constants (k(dis)) were estimated in vitro. Results for 902 were: in vitro k(dis) (pH 7.4) = 150 ng/cm2/h; after 5 days of fiber inhalation (IH), lung clearance of fibers > 20 microm length (F > 20 microm) indicated a weighted half-time (WT(1/2)) of 6.8 days and 90% clearance time (T90) of 33 days; following intratracheal instillation (IT), lung clearance half-time (T(1/2)) for F > 5 microm was 20 days. Results for 901F were: k(dis) (pH 7.4) = 500-560; after 5 days of fiber inhalation exposure, WT(1/2) (F > 20 microm) = 8.1 days and T90 = 38 days. After 5 days of fiber inhalation, both fibers induced initial pulmonary inflammation followed by return to normal within 3 wk postexposure. Lung clearance half-times for 902 and 901F passed the European Union (EU) criteria for noncarcinogenic fibers (IH WT(1/2) F > 20 microm was < 10 days); 902 passed the noncarcinogenic criterion of the German government (IT T(1/2) F > 5 microm was < 45 days). Thus, carcinogenicity labeling is not required for either fiber in the EU. Short-term test results for 902 and 901F were similar to results for synthetic vitreous fibers (SVFs) that were innocuous in rodent chronic inhalation studies, but short-term test results for 902 and 901F differed sharply from results for other SVFs that were pathogenic in chronic studies. Thus, these short-term tests indicate that 902 and 901F are biosoluble fibers and would be nonpathogenic in the rat exposed by inhalation.

Are psychiatrists' characteristics related to how they care for depression in the medically ill? Results from a national case-vignette survey

The authors' goal was to examine the relationship between psychiatrists' characteristics and their decisions regarding depression care. A national sampling of 278 psychiatrists answered diagnosis and treatment questions for one of four case vignettes with depression and various degrees of medical comorbidity. They also responded to a questionnaire assessing practice and demographic characteristics. Tendency to diagnose major depression was significantly associated with being board certified, being in practice for less time, having a greater percentage of patients with managed care, and having a greater percentage of patients on psychotropic medications. Tendency to recommend an antidepressant was significantly associated with the psychiatrist being male, being less satisfied with practice, and having a greater percentage of patients on psychotropic medications. These findings remained significant even after controlling for case characteristics. Diagnostic and prescribing tendencies of psychiatrists appear to be associated with specific physician characteristics and not simply case characteristics. These findings have implications for further studies of predictors of quality of care.

Biopersistence of synthetic vitreous fibers and amosite asbestos in the rat lung following inhalation

Fiber biopersistence as a major mechanism of fiber-induced pathogenicity was investigated. The lung biopersistence of 5 synthetic vitreous fibers (SVFs) and amosite asbestos was evaluated using the rat inhalation model. In contrast to several previous studies, this study examined fibers that dissolve relatively slowly in vitro at pH 7.4. Fisher rats were exposed for 5 days by nose-only inhalation to refractory ceramic fiber (RCF1a), rock (stone) wool (MMVF21), 2 relatively durable special application fiber glasses (MMVF32 or MMVF33), HT stonewool (MMVF34), amosite asbestos, or filtered air. Lung burdens were analyzed during 1 year post-exposure. Fiber aerosols contained 150-230 fibers/cc longer than 20 micrometer (>20 micrometer). On post-exposure Day 1, long-fiber lung burdens for the 6 test fibers were similar (12-16 x 10(5) fibers/lung >20 micrometer). After 1 year, the percentage of fibers >20 micrometer remaining in the lung was 0.04-10% for SVFs but 27% for amosite. Lung clearance weighted half-times (WT1/2) for fibers >20 micrometer were 6 days for MMVF34, 50-80 days for the other 4 SVFs, and >400 days for amosite. This study and 3 previous studies demonstrate a broad range of biopersistences for 19 different SVFs and 2 asbestos types. Ten of these fibers also have been (or are being) tested in chronic inhalation studies; in these studies, the very biopersistent fibers were carcinogenic (amosite, crocidolite, RCF1, MMVF32, and MMVF33), while the more rapidly clearing fibers were not (MMVF10, 11, 21, 22, and 34). These studies demonstrate the importance of biopersistence as an indicator of the potential pathogenicity of a wide range of fiber types.

Radiographic and spirometric findings in diatomaceous earth workers

Diatomaceous earth is a noncrystalline form of silica; in processing, calcining leads to formation of cristobalite, a form of crystalline silica. Four hundred ninety-two currently employed diatomaceous earth workers in a large mine and processing facility had chest radiographs performed and interpreted by the International Labour Office (ILO) system. Two hundred sixty-seven subjects underwent spirometry testing. Exposure indices for total dust (largely diatomaceous earth) and cristobalite were reconstructed for each individual based upon personnel records. Analysis demonstrated the following prevalences of radiographic findings: 5% had ILO scores > or = 1/0, and 25% had scores of 0/1 or higher. Regression analyses showed that there was a relationship between both total cristobalite exposure and total dust (largely diatomaceous earth) exposure and the ILO score. Radiographic patterns are not typical of those of classic silicosis. Linear regression analyses for forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio did not demonstrate a relationship between cumulative exposure and lung function. Such analyses were performed using all subjects and stratified by smoking status. There were differences in spirometric data according to radiographic ILO category, but the results were inconsistent and did not permit determining if physiologic changes are associated with radiographic change or if this is due to confounding. Overall, the study suggests that diatomaceous earth pneumoconiosis (radiographically defined) is an entity distinct from silicosis. Recent exposure levels may produce radiographic abnormalities but do not lead to demonstrable physiologic effect. The prevalence of the disorder has diminished markedly in response to modern dust control measures. Ongoing medical surveillance is recommended in workers with potential exposure to significant quantity of material.

ApoE-4 and age at onset of Alzheimer's disease: the NIMH genetics initiative

OBJECTIVE

To explore the impact of apoE-4 on Alzheimer's disease (AD) and its age at onset.

DESIGN

A genetic linkage study using affected relative pairs, predominantly siblings.

SETTING

Three academic medical centers ascertained subjects from memory disorder clinics, nursing homes, and the local community.

SUBJECTS

310 families including 679 subjects with AD by NINCDS/ADRDA and/or Khachaturian criteria and 231 unaffected subjects.

OUTCOME MEASURE

ApoE genotype. ANALYTIC METHODS: Association, affected pedigree member, sibling pair, and lod score analyses.

RESULTS

ApoE-4 was strongly associated with AD in this sample (allele frequency = 0.46 vs. 0.14 in controls, p < 0.000001). Results of lod score, affected pedigree member analysis, and sib-pair analysis also supported apoE-4 as a risk factor for AD. When the sample was stratified on family mean age at onset, the risk conferred by apoE-4 was most marked in the 61 to 65 age group. Individuals with two copies of apoE-4 had a significantly lower age at onset than those with one or no copies (66.4 vs. 72.0, p < 0.001), but individuals with one copy did not differ from those with none. Within families, the individual with the earliest age at onset had, on average, significantly more apoE-4 alleles (p < 0.0001) than the individual with the latest onset.

DISCUSSION

This work supports previous reports of an association between apoE-4 and the development of AD and demonstrates that apoE-4 exerts its maximal effect before age 70. These findings have important implications for the potential use of apoE genotyping for diagnosis and prediction of disease. They also underscore the need to identify additional genetic factors involved in AD with onset beyond age 70 years.

Implementing a human services program: how hard will it be?

A framework is presented for examining obstacles to the implementation of human services delivery programs. These obstacles appear to arise from three basic sources: (1) from the operational demands implied by a particular program concept, (2) from the nature and availability of the resources required to run the program, and (3) from the need to share authority with, or retain support of, other bureaucratic and political actors in the implementation process. Within these three broad categories, fifteen areas deserve special attention: the people to be served, the nature of the service, the likelihood of distortions or irregularities, the controllability of the program, money, personnel, space, supplies and technical equipment, and intersections with overhead agencies, other line agencies, elected politicians, higher levels of government, private-sector providers, special-interest groups, and the press. By searching each of these fifteen areas diligently and systematically--with the aid of some 44 "factors for consideration"--it appears possible to make relatively powerful predictions about the obstacles that the implementation of a given human services program will entail. In addition, the framework can be used as a comparative instrument in allocating scarce political, managerial, and financial resources among human services programs, and as an aid to decision-making within particular programs and to identifying obstacles that cut across programs. Finally, some general guidance is offered on how implementing agency managers might deal with one of the more important and difficult dimensions of program implementation--namely, getting the cooperation of players in the implementation game whom the managers do not control, and who have different interests and agendas.

Plasma cholesterol and triglyceride distributions in 13,665 children and adolescents: the Prevalence Study of the Lipid Research Clinics Program

The age-, race-, sex-specific distributions for plasma cholesterol (CH) and triglyceride (TG) are described for the 13,655 individuals under 20 years of age who were examined at the first visit (visit I) of the Prevalence Study of the Lipid Research Clinics (LRC) Program. Composite findings are presented from the seven North American LRC's where children were included in the target population. Cholesterol values are higher for blacks than for whites, but triglyceride values are higher for whites than for blacks. In both the CH and TG distributions for the combined races, the mean values for females are generally higher than for males. For cholesterol, consistent age-associated differences occur. On average, the CH values peak in late childhood and decline during adolescence. The decrease in mean values for CH is most marked for white males. The values for TG tend to increase in early adolescence. This report expands the available information about lipid distributions in young populations and describes the extent of the variation in plasma lipids associated with race and sex for each year of age, 0 to 19 years.

Prophylactic transfusions of normal red blood cells during pregnancies complicated by sickle cell hemoglobinopathies

Prophylactic transfusions of normal donor red cells were administered during 37 pregnancies to women with sickle cell anemia, sickle cell-hemoglobin C disease, or sickle cell-beta thalassemia disease. Once the diagnosis was confirmed, the transfusions were administered intermittently throughout the rest of the pregnancy in such amounts and at such frequencies that no more than 60% of the circulating red cells contained hemoglobin S and the hematocrit was above 25. The maternal mortality rate was zero and maternal morbidity as the consequence of the sickle cell hemoglobinopathy was minimal. The perinatal mortality rate was appreciably reduced when compared to that previously observed without prophylactic transfusions but perinatal morbidity was still excessive. Evidence that the intrauterine environment was compromised, in spite of the transfusions consisted of an increased frequency of growth-retarded fetuses, of meconium staining of amnionic fluid, and of ominous decelerations of fetal heart rate. Morbidity from the transfusions was troublesome. Nonetheless, it is concluded tentatively that both the mother with a sickle cell hemoglobinopathy and her fetus are likely to benefit from prophylactic transfusions of normal donor red cells administered during one pregnancy according to the protocol employed in this study.

Drug utilization review in an HMO. I. Introduction and examples of methodology

An experimental drug utilization review program was developed for a health maintenance organization (HMO). The objectives of the program were to develop and implement an ongoing mechanism for reviewing drug use using criteria based on the scientific literature, and to evaluate the effect of the drug use review program on physician precribing patterns. Seven therapeutic categories of drugs, accounting for over 65 per cent of prescribing, were selected and criteria developed for their use. The drug use review prcedure is described briefly. The evaluation of the drug use review program is based on a comparison of rates of prescription use for specific therapeutic categories before and after the criteria were ceveloped and approved. As an example, data for the antihistamine therapeutic category are presented. Criteria for prescribing antihistamines suggested restricting use of combination cold preparations and refraiming from antihistamine use in viral upper respiratory tract infections. After the criteria were adopted, prescribing of antihistamines for viral URIs declined, particularly in pediatrics. In general, prescribing of combination antihistamine preparations did not change; where one combination preparation was deleted from the formulary, prescribers appeared to substitute another combination preparation.

Cyclophosphamide protection in NZB/NZW disease. Mechanisms and therapeutic regimens

Regular administration of cyclophosphamide to NZB/NZW female mice effectively protects against the nephritis that is thought to be a model for human SLE nephritis. Reductions in serologic, histologic, and immunogluorescent parameters of the disease are correlated. Intermittent as well as continuous administration of the drug is effective without the development of leukopenia. Possible mechanisms of drug action and a modified approach to therapy of immune complex disease are discussed.

A longitudinal study of total body potassium in normal children

Most investigators studying changes in body composition during growth agree to the desirability of having longitudinal data. A group of 110 boys and 126 girls, studied annually for 4-5 years with 880 measurements of total body K in a 2pi liquid scintillation whole body counter, had total body K vs. height and total body K vs. weight data that fit previously described regression lines.

Reproductive performance of male and female phenotypes in three sex chromosomal genotypes(XX, XY, YY) in the killifish, Oryzias latipes

The present study investigates the juvenile and adult reproductive performance of Japanese killifish, Oryzias latipes, which were successfully sex-reversed by feeding them male or female sex hormones during the fry stage. Sexual maturation of these laboratory grown fish of three known genotypes (XX, SY, YY) occurred earliest in untreated genotypes, next in genotypes treated with male hormone (methyl testosterone) and female hormone (estrone), respectively. The delay in sexual maturation caused by early exogenous, sex-hormone treatment may represent a disturbance in the delicate neural-gonadal axis. However, the degree of response was also strongly influenced by the animal's sex chromosomal genotype. XX fish, normally phenotypic females, were affected more by the male hormone than by the female hormone. XY and YY fish, normally phenotypic males, were delayed more by the female hormone than by the male hormone. This specific sex hormone-sex genotype interaction also influenced adult reproductive performance (sperm or egg production). Differences in the metabolism of male and female sex hormones by the XX, XY, and YY fish are probably responsible for these interesting findings.

A computer-oriented linkage analysis scheme

A comprehensive, computer-oriented scheme for genetic linkage analysis is described. It computes the likelihood of a complex pedigree allowing for many non-standard features including multiple alleles (up to four per locus), multiple mates, more than one mating in the eldest generation, consanguinity, missing or partially tested persons, and different recombination fractions between males and females. The program works by computing weighted likelihoods in a vertical, descending fashion. First, the set of possible genotypes for the members of the eldest generation is determined and prior probabilities assigned to these states of nature (based on gene frequency calculations). Phenotypic information is used to modify these probabilities in the standard manner. Then, for a particular set of genotypes, the conditional likelihood of the remainder of the pedigree is computed. This calculation may itself be many-branched and therefore a computer is necessary to keep track of the stages of the process. When the youngest generation has been taken into account, a final likelihood is determined, reflecting all information in the pedigree. The current version of the program successfully calculates the exact likelihood of a complex pedigree which was designed to exploit the non-standard features of the program. It has also computed likelihoods for a published pedigree, and the results are essentially equal to those obtained by the other authors using a previously available computer scheme for linkage analysis.