A maturity model for the scientific review of clinical trial designs and their informativeness

BACKGROUND

Informativeness, in the context of clinical trials, defines whether a study's results definitively answer its research questions with meaningful next steps. Many clinical trials end uninformatively. Clinical trial protocols are required to go through reviews in regulatory and ethical domains: areas that focus on specifics outside of trial design, biostatistics, and research methods. Private foundations and government funders rarely require focused scientific design reviews for these areas. There are no documented standards and processes, or even best practices, toward a capability for funders to perform scientific design reviews after their peer review process prior to a funding commitment.

MAIN BODY

Considering the investment in and standardization of ethical and regulatory reviews, and the prevalence of studies never finishing or failing to provide definitive results, it may be that scientific reviews of trial designs with a focus on informativeness offer the best chance for improved outcomes and return-on-investment in clinical trials. A maturity model is a helpful tool for knowledge transfer to help grow capabilities in a new area or for those looking to perform a self-assessment in an existing area. Such a model is offered for scientific design reviews of clinical trial protocols. This maturity model includes 11 process areas and 5 maturity levels. Each of the 55 process area levels is populated with descriptions on a continuum toward an optimal state to improve trial protocols in the areas of risk of failure or uninformativeness.

CONCLUSION

This tool allows for prescriptive guidance on next investments to improve attributes of post-funding reviews of trials, with a focus on informativeness. Traditional pre-funding peer review has limited capacity for trial design review, especially for detailed biostatistical and methodological review. Select non-industry funders have begun to explore or invest in post-funding review programs of grantee protocols, based on exemplars of such programs. Funders with a desire to meet fiduciary responsibilities and mission goals can use the described model to enhance efforts supporting trial participant commitment and faster cures.

5-HT2A Agonists: A Novel Therapy for Functional Neurological Disorders?

Functional neurological disorders are frequently encountered in clinical practice. They have a poor prognosis and treatment options are limited. Their etiology is unknown, but leading theories propose a disturbance of somatic self-representation: the mind perceives dysfunction of a body region despite intact motor and sensory pathways. Central to this model is the concept of an abnormal top-down cognitive influence upon sensorimotor function. There is growing interest in the use of 5-HT2A agonists in the management of neuropsychiatric conditions. Recent studies have shown that these agents induce changes in neural activity that disrupt hierarchical brain dynamics and modulate networks subserving self-related processing. Converging evidence suggests they may hold unique therapeutic potential in functional neurological disorders. This is of importance given the considerable personal and societal burden of this condition and we argue a clinical trial to test this hypothesis is warranted.

A multicenter retrospective study of 151 renal biopsies in horses

BACKGROUND

Renal biopsies are uncommonly performed in horses and little is known about their diagnostic utility and associated complication rate.

OBJECTIVE

To describe the techniques, the complication rate, risk factors, and histopathology results; as well as evaluate the safety and diagnostic utility of renal biopsy in the horse.

ANIMALS

One hundred and forty-six horses from which 151 renal biopsies were obtained. Animals ranged in age from 48 hours to 30 years.

METHODS

Multicenter retrospective study, with participation of 14 institutions (1983-2009).

RESULTS

Renal biopsy in horses was associated with a similar rate of complications (11.3%) to that occurring in humans and companion animals. Complications were generally associated with hemorrhage or signs of colic, and required treatment in 3% of cases. Fatality rate was low (1/151; 0.7%). Biopsy specimens yielded sufficient tissue for a histopathologic diagnosis in most cases (94%) but diagnoses had only fair (72%) agreement with postmortem findings. Risk factors for complications included biopsy specimens of the left kidney (P = .030), a diagnosis of neoplasia (P = .004), and low urine specific gravity (P = .030). No association with complications was found for age, sex, breed, institution, presenting complaint, other initial clinicopathologic data, biopsy instrument, needle size, or use of ultrasonographic guidance.

CONCLUSIONS AND CLINICAL IMPORTANCE

Renal biopsy in horses has low morbidity and results in a morphological histopathologic diagnosis in 94% of cases. However, this procedure might result in serious complications and should only be used when information obtained would be likely to impact decisions regarding patient management and prognosis.

The impact of a changed environment on arousal levels of patients in a secure extended rehabilitation facility

OBJECTIVE

This study sought to investigate the effect of changes of the physical ward environment on levels of arousal and aggression in long-stay patients in a secure extended rehabilitation facility.

METHOD

Seclusion episodes, extended seclusion episodes, staff report of aggressive incidents and Brief Psychiatric Rating Scale (BPRS) measures of psychopathology were compared in the same group of long-stay rehabilitation patients over a period of 3 months before and 3 months after a move from a temporary, refurbished medical ward to a large, light-filled, purpose-built facility.

RESULTS

Fifteen patients were present during both investigation periods. The majority were male (80%) and had a diagnosis of schizophrenia (53%) or schizoaffective disorder (13%). There were statistically significant reductions in the mean number of seclusion episodes, mean number of extended seclusion episodes (> 4 hours) and BPRS total score following the move. There were statistically significant increases in ambient light conditions in the new unit.

CONCLUSIONS

The physical environment of long-stay rehabilitation wards may influence aggressive behaviour and arousal in chronically ill patients.

Stability of cognitive impairment in chronic schizophrenia over brief and intermediate re-test intervals

OBJECTIVE

This study examined between- and within-subject stability of cognitive performance in individuals with chronic schizophrenia.

METHODS

Thirty individuals with schizophrenia and 20 healthy controls matched by age, sex, education, and estimated IQ underwent repeated cognitive assessments at baseline and 30 days using computerized tests of psychomotor function, visual attention/information processing, non-verbal learning, and executive function.

RESULTS

Compared to healthy controls, individuals with schizophrenia scored lower on all cognitive measures and demonstrated greater variability in cognitive performance. Within-subject variability in cognitive performance in both the schizophrenia and healthy control groups remained stable at brief (i.e., hours) and intermediate (i.e., one month) assessments.

CONCLUSIONS

These results demonstrate the stability of between- and within-subject variability in cognitive performance in schizophrenia, and suggest that variability in cognitive performance may reflect an inherent characteristic of the disorder, rather than differences in test-retest reliability/error of cognitive measures.

Spatial working memory and problem solving in schizophrenia: the effect of symptom stabilization with atypical antipsychotic medication

Reasoning and problem solving in the spatial domain are important aspects of executive function that are reliably impaired in schizophrenia, and the Groton Maze Learning Test(c) (GMLT) provides a valid measure of spatial working memory. In the current study, 34 patients with first-episode schizophrenia and 20 matched controls were assessed for baseline spatial working memory abilities using this hidden maze learning test. Approximately one month after baseline assessment, allowing for symptoms to stabilize in response to treatment with therapeutic doses of atypical antipsychotic medications for individuals with schizophrenia, all participants were again assessed with the GMLT. Prior to pharmacologic intervention, patients with schizophrenia showed significant impairments in performance of all aspects of the GMLT, including measures of learning efficiency and error monitoring. One month of treatment was associated with a reliable improvement in these domains, although impairments in accuracy and error monitoring on this spatial working memory test persisted despite symptomatic improvement. These results indicate that impairments in spatial working memory are present at the earliest stages of the illness, and that such deficits in performance remain present, albeit ameliorated, after treatment with atypical antipsychotic medication.

Dopamine dysregulation syndrome: implications for a dopamine hypothesis of bipolar disorder

OBJECTIVE

Rational therapeutic development in bipolar is hampered by a lack of pathophysiological model. However, there is a wealth of converging data on the role of dopamine in bipolar disorder. This paper therefore examines the possibility of a dopamine hypothesis for bipolar disorder.

METHOD

A literature search was conducted using standard search engines Embase, PyschLIT, PubMed and MEDLINE. In addition, papers and book chapters known to the authors were retrieved and examined for further relevant articles.

RESULTS

Collectively, in excess of 100 articles were reviewed from which approximately 75% were relevant to the focus of this paper.

CONCLUSION

Pharmacological models suggest a role of increased dopaminergic drive in mania and the converse in depression. In Parkinson's disease, administration of high-dose dopamine precursors can produce a 'maniform' picture, which switches into a depressive analogue on withdrawal. It is possible that in bipolar disorder there is a cyclical process, where increased dopaminergic transmission in mania leads to a secondary down regulation of dopaminergic receptor sensitivity over time. This may lead to a period of decreased dopaminergic transmission, corresponding with the depressive phase, and the repetition of the cycle. This model, if verified, may have implications for rational drug development.

Neuropsychological study of underweight and "weight-recovered" anorexia nervosa compared with bulimia nervosa and normal controls

OBJECTIVE

To compare executive, memory and visuospatial functioning of DSM-IV anorexia nervosa (AN), bulimia nervosa (BN), and normal controls (NC).

METHOD

A comparison of women involving: (i) 16 AN with body mass indices (BMI) < or = 17.5 kg/m(2); (ii) 12 AN with BMI > 18.5 kg/m(2) for at least 3 months; (iii) 13 BN; and (iv) 16 NC participants was performed with groups of similar age and intelligence. Groups were assessed with EDE-12, MADRS, HAMA, Cognitive Drug Research (CDR) battery, and Bechara tasks.

RESULTS

Significant impairments in CDR Power of Attention were present in underweight AN and BN participants. CDR Morse Tapping was significantly impaired in all clinical groups. The BN and weight-recovered AN groups were significantly impaired on CDR immediate word recall. The BN group alone was significantly impaired on CDR delayed word recall.

CONCLUSION

Attentional impairment is similar in AN and BN. Impaired motor tasks in AN persist after "weight-recovery" and are similar to impairments in BN. BN may be discriminated from AN on word recall.

Dopamine dysregulation syndrome: implications for a dopamine hypothesis of bipolar disorder

OBJECTIVE

Rational therapeutic development in bipolar is hampered by a lack of pathophysiological model. However, there is a wealth of converging data on the role of dopamine in bipolar disorder. This paper therefore examines the possibility of a dopamine hypothesis for bipolar disorder.

METHOD

A literature search was conducted using standard search engines Embase, PyschLIT, PubMed and MEDLINE. In addition, papers and book chapters known to the authors were retrieved and examined for further relevant articles.

RESULTS

Collectively, in excess of 100 articles were reviewed from which approximately 75% were relevant to the focus of this paper.

CONCLUSION

Pharmacological models suggest a role of increased dopaminergic drive in mania and the converse in depression. In Parkinson's disease, administration of high-dose dopamine precursors can produce a 'maniform' picture, which switches into a depressive analogue on withdrawal. It is possible that in bipolar disorder there is a cyclical process, where increased dopaminergic transmission in mania leads to a secondary down regulation of dopaminergic receptor sensitivity over time. This may lead to a period of decreased dopaminergic transmission, corresponding with the depressive phase, and the repetition of the cycle. This model, if verified, may have implications for rational drug development.

An open-label study of quetiapine in anorexia nervosa

BACKGROUND

Atypical antipsychotics may be beneficial in treating the core psychopathology of anorexia nervosa (AN).

METHODS

An 8 week open-label study of quetiapine was conducted in eight severely ill DSM-IV AN patients consecutively admitted to a specialist eating disorders unit. Participants were assessed by EDE-12, MADRS, YBOCS, SAPS-delusions and CDR neuropsychological battery at baseline, 4 weeks and 8 weeks, and by weekly body mass index (BMI), CGI and extrapyramidal scores. Quetiapine doses ranged from 50 mg to 800 mg per day, according to efficacy and tolerability.

RESULTS

Seven participants completed 4 weeks and five participants completed 8 weeks. All participants had clinically significant levels of specific eating disorders psychopathology, and mild to moderately severe depressive symptomatology. Apart from initial mild sedation, no subjects experienced any significant adverse events. Over 4 weeks there was no significant difference in BMI, but a significant difference in the EDE-12 restraint score. There were significant differences on BMI and EDE-12 restraint subscale scores over 8 weeks.

CONCLUSIONS

A double-blind placebo controlled study is required to further evaluate the therapeutic utility of quetiapine in severely ill AN patients beyond multidisciplinary specialist intervention.

Depression and anxiety: pharmacological treatment in general practice

BACKGROUND

Depression and anxiety are common presentations in general practice and medications are one of the key treatment strategies.

OBJECTIVE

This article provides an overview of important practical issues to consider when prescribing medications for anxiety and depression.

DISCUSSION

Key questions for the general practitioner to consider are: Are medications the best option? Which is the best medication for this patient? What are the practical aspects of prescribing this medication? What is the next step if it doesn't work?

Pharmacokinetics of imipenem-cilastatin following intravenous administration in healthy adult horses

In two studies, six healthy adult horses were given imipenem-cilastatin by slow intravenous (i.v.) infusion at an imipenem dosage of 10 mg/kg (study 1) and 20 mg/kg (study 2). The same horses were used in each dosage schedule, with a 2-week washout period between studies. In each dosage group, serial blood and synovial fluid samples were collected for 6 h after completion of the infusion. HPLC was used to determine the imipenem concentration in all samples. Imipenem was well tolerated by all horses at both dosages; no adverse effects were noted during the study period or during the 24-hour postinfusion observation period. The pharmacokinetic profiles of imipenem in the plasma and synovial fluid indicate that an imipenem dosage of 10-20 mg/kg by slow i.v. infusion q6h (every 6 h) is appropriate for most susceptible pathogens.

Serotonergic and dopaminergic systems in anorexia nervosa: a role for atypical antipsychotics?

OBJECTIVE

To review serotonergic and dopaminergic system function in anorexia nervosa in terms of potential modulation by atypical antipsychotic medications.

METHOD

A systematic review of clinical, neurobiological and functional neuroimaging findings of serotonergic and dopaminergic system activity in anorexia nervosa was conducted via MEDLINE, PsycINFO and EMBASE psychiatry databases, with a critical review of dysregulation of these systems as therapeutic targets for atypical antipsychotics, in context of evidence regarding the utility and efficacy of these medications in this syndrome.

RESULTS

There is evidence of persistently altered serotonergic and dopaminergic function in anorexia nervosa independent to weight-recovery. Case reports, open-label and single-blinded studies, albeit sparse, suggest that atypical antipsychotics may be beneficial in the management of anorexia nervosa psychopathology beyond weight gain.

CONCLUSIONS

Double-blind placebo controlled studies of atypical antipsychotics in anorexia nervosa with well defined outcome measures are required.

Cefotaxime kinetics in plasma and synovial fluid following intravenous administration in horses

Cefotaxime powder was diluted with sterile water to a concentration of 100 mg/mL. The volume of solution was adjusted for each experimental horse to provide a total dose of 15, 20, and 25 mg/kg and was administered by infusion through a jugular vein catheter over a 10-min period. All three doses were administered to each of the six experimental horses at three different times. Cefotaxime concentrations in plasma and synovial fluid samples were measured by high-performance liquid chromatography (HPLC). Standard compartmental analysis techniques and the WinSAAM modeling program were used to determine standard pharmacokinetic parameters for cefotaxime. The plasma and synovial fluid data from the five horses administered the 25 mg/kg dose was analyzed. Plasma cefotaxime concentrations appeared to be linearly related to dose infused and declined in parallel, suggesting linear drug kinetics. Moreover, cefotaxime concentrations declined monotonically suggesting that its disposition kinetics could essentially be described by a one-compartment model rather than the fact that sampling occurred after the infusion was discontinued. Maximum concentration of cefotaxime in plasma occurred immediately after cessation of the infusion. Minimum inhibitory concentrations were determined for Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, and Klebsiella pneumoniae, common isolates from septic arthritis in horses. Based on our pharmacokinetic data, a regimen of 25 mg/kg administered i.v. every 6 h appears appropriate for susceptible joint infections in adult horses.

Prolactin response to d-fenfluramine in combat-related post-traumatic stress disorder

Central serotonergic function can be investigated by measuring the prolactin response to the serotonin releasing/uptake agent, d-fenfluramine. This study investigated the effect of diagnosis, depressive symptoms and history of alcohol or tobacco abuse or dependence on the d-fenfluramine test in combat-related post-traumatic stress disorder (PTSD). Male, non-hospitalized combat-exposed veterans diagnosed with PTSD (DSM-III-R) and a similarly aged combat-exposed control group were assessed for both PTSD and depressive symptoms and prolactin responses to a 30-mg d-fenfluramine challenge test. Ninety-five subjects were studied; 23 were controls, 46 subjects met the criteria for current PTSD and 26 for past PTSD. There were no significant differences between the three groups for baseline prolactin, peak prolactin, and time to reach peak, delta prolactin or area under the curve of the prolactin vs. time curve. Depressive symptoms and history of alcohol or tobacco abuse or dependence did not have a confounding effect on the prolactin responses to d-fenfluramine. This study suggests that a blunted prolactin response to d-fenfluramine may be a consequence of combat exposure rather than PTSD. To confirm this, further studies involving both healthy and combat-exposed control groups in addition to subjects with PTSD of similar ages are required.

The emerging role of pharmacogenetics: implications for clinical psychiatry

OBJECTIVE

This article aims to review the implications of pharmacogenetics for clinical psychiatry; these are discussed in the context of environmental and sociocultural factors.

METHOD

A selective literature review was conducted using Medline search and other relevant references available to the authors.

RESULTS

The individual differences in therapeutic and adverse effects of psychotropic drugs are largely determined by genetic factors. Recent advances in pharmacogenetics have highlighted the potential utility in predicting metabolic phenotypes, risks for side-effects and likelihood of drug response for the individual patient.

CONCLUSIONS

Genotyping, especially for drug metabolizing enzymes, could enable more rational, cost-effective and optimal prescribing in future psychopharmacotherapy. Although the advances of pharmacogenetics may have many benefits in clinical practice, the importance of non-genetic factors must also be considered as cultural and environmental factors significantly impinge on response to medications. To clarify the extent pharmacogenetics can be adopted in clinical practice to predict drug response in patients from diverse backgrounds, further studies in different ethnic groups and clinical settings are required.

Blunted growth hormone response to clonidine in post-traumatic stress disorder

Hyperactivity of the sympathetic and noradrenergic systems is thought to be a feature of post-traumatic stress disorder (PTSD). Assessment of noradrenergic receptor function can be undertaken by measuring the growth hormone (GH) response to the alpha2-agonist clonidine. The aim of this study was to examine whether subjects with combat-related PTSD (with or without co-morbid depression) have a blunted growth hormone response to clonidine, compared to a combat-exposed control group. Twenty-three Vietnam veterans suffering from PTSD alone, 27 suffering from PTSD and co-morbid depression, and 32 veteran controls with no psychiatric illness were administered 1.5 microg/kg clonidine i.v. Plasma growth hormone was measured every 20 min for 120 min. The growth hormone response to clonidine was significantly blunted in the non-depressed PTSD group compared to both the depressed PTSD group and the control group as measured by peak growth hormone, delta growth hormone and AUC growth hormone. Subjects with PTSD and no co-morbid depressive illness show a blunted growth hormone response to clonidine. This suggests that post-synaptic alpha2-receptors are subsensitive. This finding is consistent with other studies showing increased noradrenergic activity in PTSD.

Blunted prolactin response to D-fenfluramine in post-stroke major depression

BACKGROUND

This study investigated whether patients suffering from post-stroke depressive disorder had a similar disturbance in central serotonergic function to that described in non-brain injured depressed patients.

METHODS

Twenty-three depressed patients (nine major, 14 minor) and 38 non-depressed patients were examined 4-8 weeks post-stroke with a structured interview, rating scales and MRI brain scans. Patients were administered 30 mg D-fenfluramine orally and plasma prolactin and D-fenfluramine concentrations were measured for 6 h post-dose.

RESULTS

The prolactin response was significantly blunted in major depression compared to minor depression and non-depressed patients as measured by both delta prolactin and area under the prolactin versus time curve. There was no significant relationship between prolactin response and lesion lateralization or any of the measured clinical characteristics.

LIMITATIONS

The major limitation of the study is the relatively small number in each depressive group.

CONCLUSIONS

Patients suffering from major depression in the post-stroke period have a blunted prolactin response to D-fenfluramine. This indicates a serotonergic abnormality consistent with that found in major depression where neurological disease is not present.

In vitro performance of intramedullary cement restrictors in total hip arthroplasty

Contemporary cementing techniques in total hip arthroplasty include the use of a cement restrictor to occlude the intramedullary canal. As there are many different designs currently available it was the aim of our study to compare the stability of eight different systems. We investigated the displacement and the ability to occlude the femur of these cement restrictors during standardised cementing of artificial and fresh frozen femora. The maximal intramedullary pressures and the displacement of the plugs were continuously recorded and statistically evaluated. The results revealed significant differences between the tested cement restrictors. The expandable REX Cement Stop and the Exeter Plug achieved the highest stability and the least cement leakage. The more rigid designs (Palacos Plug, BUCK, Universal) in contrast showed inferior performance. Our biomechanical study emphasises the importance of cement restrictor selection, which can have a crucial influence on the fixation of a cemented total hip replacement.

The evaluation of depression in inpatients with HIV disease

OBJECTIVES

The aim of this paper is: to compare the utility of four approaches to the diagnosis of depression in patients with human immunodeficiency virus (HIV) disease; to examine the utility of four rating scales to assess the presence and severity of depression; and to devise a set of substitutive criteria that would be appropriate in patients with HIV disease.

METHOD

A group of inpatients was assessed using standard clinical interview. Patients found to have major depression using DSM-III-R (aetiological) criteria were assessed using inclusive, substitutive and exclusive criteria for the diagnosis of depression. Severity was assessed using the Hamilton Depression Rating Scale (HDRS), the Montgomery Asberg Depression Rating Scale (MADRS), the Beck Depression Inventory (BDI), and the Centre for Epidemiological Studies Depression Rating Scale (CES-D). A group of control patients were matched for age and severity of HIV illness.

RESULTS

Seventeen patients met DSM-III-R (aetiological criteria) for major depression. All were male; they had a mean age of 40.6 years and one-third had acquired immune deficiency syndrome (AIDS). Using alternative approaches to the diagnosis of depression, up to five additional 'depressed' patients were identified ('false positives'). All 17 patients meeting the DSM-III-R criteria also met the substitutive and exclusive criteria but only 15 exclusive criteria. Of the 17 controls (not meeting DSM-III-R criteria), two met substitutive, five inclusive and one exclusive criteria for depression. The mean (+/- SD) scores for the patients and controls were significantly different on all four rating scales. Analysis of individual items on the rating scales revealed that a number did not show significant differences between the depressed and nondepressed groups: on the MADRS the items lassitude and inner tension; on the HDRS the three items depicting anxiety symptoms, loss of libido, hypochondriasis, loss of weight, and maintenance of insight; on the BDI a sense of being punished, disappointed in self, being self-critical, a feeling of looking unattractive, fatigue, weight loss, worried about health and loss of libido; on the CES-D I felt just as good as others, hopeful, talk less, people unfriendly and felt people dislike me.

CONCLUSIONS

The aetiological approach used by clinicians familiar with the features of HIV disease, was found to be useful. All four rating scales differentiated equally well between depressed and non-depressed groups.

Negative symptoms, depression, and parkinsonian symptoms in chronic, hospitalised schizophrenic patients

BACKGROUND

Negative symptoms of schizophrenia are often confounded by overlapping depressive and parkinsonian symptoms. The role of medication as an aetiological factor in the development of these symptoms is an important issue for prevention and treatment.

METHODS

A total of 45 inpatients in chronic wards who met RDC criteria for schizophrenia were assessed with the Hamilton depression rating scale (HDRS) and negative symptom rating scale (NSRS) and the targeting abnormal kinetic effect scale (TAKE).

RESULTS

No significant correlation was found between the total scores on the vegetative superfactor of the HDRS and the NSRS. Duration of neuroleptic treatment was positively correlated with depressive symptoms (r=0.299, P < 0.05) and negative symptoms (r=0.443, P < 0.001). Dose of antipsychotic was also correlated positively with negative symptoms (r=0.260, P < 0.05). Age was negatively correlated with depressive symptoms as assessed by the HDRS (r=0.306, P <0.05).

CONCLUSION

The data suggest that depressive and negative symptoms can be separated in chronic schizophrenia, while pointing to a possible role of antipsychotic medication in the aetiology.

LIMITATIONS

The study was conducted in a small chronically hospitalised population treated with relatively high doses of antipsychotics. It is not clear that the results obtained here would be applicable to an acute patient population.

Platelet paroxetine binding in post-traumatic stress disorder

Sixty-two subjects, 45 with post-traumatic stress disorder (PTSD) and 17 healthy control subjects, were examined in a study of serotonin function measured by [3H]paroxetine binding to platelet membranes. Subjects were selected from male combat exposed veterans. The mean (+/- S.D.) Kd was 0.078 +/- 0.045 nM for the PTSD patient group and 0.064 +/- 0.037 nM for the control group. The mean Bmax was 934 + 238 fmol/mg protein for the PTSD patient group and 1011 +/- 363 fmol/mg protein for the control group. There was no significant difference between the groups for either Kd or Bmax before or after controlling for season of sampling. There were no significant differences between subjects with current PTSD and those with PTSD in the past, or between PTSD subjects with or without concurrent major depressive disorder. This study finds no relationship between PTSD, major depressive disorder and peripheral serotonin function measured by [3H]paroxetine binding to blood platelets.

Aggressive behaviour and platelet 3H-paroxetine binding in schizophrenia

Forty schizophrenic patients were included in a study of the relationship between serotonin function as measured by 3H-paroxetine binding to platelet membranes and aggressive behaviour. Patients classified as either aggressive or non-aggressive were paired by age, sex and duration of illness. 3H-Paroxetine binding variations were avoided by taking samples for each pair between 09:00 and 11:00 h, within 4 days of each other, and by assaying pair of samples together. The mean Kd for the aggressive group was 0.193 +/- 0.126 nM and the mean Kd for the non-aggressive group was 0.176 +/- 0.164 nM. The mean Bmax for the aggressive group was 1451 +/- 386 fmol/mg protein while the mean for the non-aggressive group was 1549 +/- 375 fmol/mg protein. There was no significant difference between the groups for either parameter, Kd or Bmax. There were no significant correlations between psychopathology rating including positive and negative symptoms, depression, suicidal thoughts, impulse control, as well as both past and present history of aggression, hostility and irritability traits, psychopathic deviance and either Bmax and Kd. This study finds no relationship between aggressive behaviour and peripheral serotonin function as measured by 3H-paroxetine binding to platelet membranes.

Patient satisfaction with pharmacologic erection program

One hundred seventy-two patients on a pharmacologic erection program for male erectile dysfunction were sent a detailed questionnaire regarding their satisfaction using intracorporeal injection with vasoactive drugs. Sixty-seven percent of patients responded. Eighty-five percent of respondents said their sex life was improved. Eighty-eight percent would recommend penile self-injection to a friend whose complaint is impotence. Despite this, 49 percent of respondents were no longer using self-injections. The results from our detailed questionnaire suggest that the majority of the patients are quite satisfied with the erections achieved with intracorporeal injection of vasoactive drugs. The high dropout rate associated with such a program may be due to reasons other than the quality of erection achieved and sexual satisfaction derived from pharmacologic erections.

Relationship of symptomatology of schizophrenia and tardive dyskinesia

The role of drug factors and patient factors in the development of tardive dyskinesia (TD) was examined in 31 TD patients and 31 non-TD patients matched by age and sex. TD patients achieved significantly lower total scores on the anxiety-depression factor of Brief Psychiatric Rating Scale (BPRS) (5.2 +/- 1.4 vs. 6.5 +/- 2.2; less than P) and significantly higher total scores on the activation factor (6.4 +/- 2.2 vs. 5.3 +/- 2.5; less than P). The finding that TD patients were less depressed may be explained by a hypermonoaminergic state developing in TD. Based on the findings of this study it is suggested that catatonic schizophrenic patients are more vulnerable to the development of TD.

Fenfluramine augmentation of clomipramine treatment of obsessive compulsive disorder

Recently, much research interest has been directed to demonstrating a possible biological basis to obsessive compulsive disorder. In particular, dysregulation in brain serotonin is suggested to be important. Two cases are described in which fenfluramine, a presynaptic 5 HT-releasing agent and 5HT-reuptake inhibitor was used to augment clomipramine treatment for OCD.

Reproductive hormones in menstrual blood

Menstrual and peripheral blood samples were collected from 19 regularly cycling women on days 1-3 of the menstrual cycle. Menstrual samples were collected with a soft silicone rubber menstrual cup. Hematocrit, PRL, LH, FSH, estradiol (E2), and progesterone (P4) were measured in all samples. Validation studies were carried out for RIAs of PRL, LH, and FSH in menstrual plasma. The menstrual plasma PRL level was significantly higher than its peripheral blood level on day 1 (63.3 +/- 14.7 and 12.1 +/- 2.9 micrograms/L, respectively; t = 3.331; P less than 0.01), and menstrual PRL was significantly higher on day 1 than on day 2 (t = 3.340; P less than 0.01). There was a strong negative correlation between log menstrual PRL concentration and time of onset of menstruation (r = -0.596; P less than 0.01). Menstrual plasma FSH levels were significantly lower than peripheral levels on each of days 1-3 (day 1:t = 4.787; P less than 0.001), and there was a significant positive correlation between menstrual and peripheral levels (r = 0.607; P less than 0.01). By contrast, menstrual plasma LH was significantly higher than the peripheral level on days 1 and 2 (day 1:t = 3.105; day 2:t = 3.180; P less than 0.01), with no correlation between menstrual and peripheral levels. Menstrual E2 was slightly lower than and significantly positively correlated with peripheral E2 (r = 0.646; P less than 0.01). Menstrual P4 was lower than but showed no correlation with peripheral levels. As expected, the menstrual blood hematocrit was less than 0.20 and highly significantly lower than that of peripheral venous blood. These results suggest that PRL is released in substantial amounts from secretory endometrium into the menstrual flow during the first day of menstrual breakdown. LH may also be released in small amounts from menstrual endometrium, while menstrual FSH, E2, and P4 probably arise entirely from the peripheral circulation.

Single oral dose pharmacokinetics of tiapride in patients with Huntington's disease

The pharmacokinetic properties of a single oral dose of 100 mg of tiapride were studied in six patients with Huntington's disease. The results for five patients were consistent with a two compartment open model. Peak plasma concentrations were observed within 2 h following drug administration with a mean value of 0.92 micrograms/ml being recorded. The drug was rapidly eliminated as unmetabolised tiapride in the urine, 51% of the dose was recovered in 24 h. The plasma elimination half-life was 5.3 h and the average apparent plasma clearance was 16.6 l/h.

A study of the dexamethasone suppression test in hospitalized depressed patients

90 patients with a primary depressive illness, admitted consecutively to one psychiatric ward were studied. All patients had the dexamethasone suppression test (DST) done before initial treatment. First treatment response was correlated with the DST results. The non-suppressors, as a group, improved with treatment better than the suppressors. However, unlike in previous studies, no relationship was found between non-suppression and poor response to antidepressant medication.

The pharmacokinetics of mianserin in elderly depressed patients

The pharmacokinetics of mianserin were examined in eight elderly depressed patients following a single oral dose of 60 mg. Plasma concentrations were measured by gas chromatography/mass spectrometry and the data analyzed using a two-compartment open model. Mean (+/- SD) estimates were: absorption half-life 0.8 +/- 1.0h, peak concentration 117 +/- 23 micrograms/l, peak time 2.2 +/- 1.3h, distribution half-life 3.4 +/- 1.2h, elimination half-life 33 +/- 15h, apparent volume of distribution 20.2 +/- 7.9 1/kg, and oral clearance 0.49 +/- 0.21 l/kg/h. These parameters were not significantly different from those found in healthy volunteers. The absorption lag time (0.6 +/- 0.2h) and area under the curve (2009 +/- 566 micrograms/l/h) were significantly different in the elderly. The clinical implications of these differences for the treatment of elderly depressed patients are discussed.

Ligand binding and platelet uptake studies of loxapine, amoxapine and their 8-hydroxylated derivatives

Loxapine, amoxapine and their 8-hydroxylated derivatives were studied by means of [3H]imipramine binding to rat cortical membranes, [3H]spiperone binding to rat striatal membranes, and the inhibition of serotonin uptake by human platelets. As inhibitors of [3H]imipramine binding: amoxapine greater than hydroxyamoxapine greater than loxapine = hydroxyloxapine; as inhibitors of platelet serotonin uptake: hydroxyamoxapine greater than amoxapine greater than hydroxyloxapine greater than loxapine; and as inhibitors of [3H]spiperone binding: loxapine greater than amoxapine greater than hydroxyamoxapine greater than hydroxyloxapine. The antipsychotic properties of loxapine and amoxapine were supported by the binding results, which also indicated the probable antipsychotic activities of the metabolites. All 4 compounds may possess dual action of antidepressant effect as well as antipsychotic effect.

A controlled comparative trial of clorazepate (Tranxene) and diazepam (Valium) for anxiety

Two groups of anxious patients were treated with either clorazepate (n = 27, 15 mg at night), or diazepam (n = 27, 5 mg three times a day), and the anxiolytic effects of the treatments compared during a 22 day period. Both drugs were effective antianxiety agents (as assessed by the Hamilton Anxiety Scale, Analogue and Rapid Symptom Check List scales). The response to drug treatment did not differ according to the type of anxiety--psychological or somatic. No significant difference was observed between the two drug treatments. Separation of patients according to their anxiety type did not change this finding. Clorazepate, when administered as a single dose at night, is an effective short term anxiolytic.

Variation of Pressure Gradient with Distance of Rectilinear Flow of Gas-saturated Oil and Unsaturated Oil through Unconsolidated Sand

Part I Of Final Report Of A. P. 1. Project No. 33

The data and information compiled under Part I of this report are the resultsof experiments performed in the petroleum engineering laboratory under thesupervision of W. F. Cloud, Associate Professor of Petroleum Engineering andWilliam Schriever, Professor of Physics, University of Oklahoma.

Problems Being Studied

Most of the time has been spent in trying to determine the rate of flow andpressure gradient in a 4-in. flow tube 10 ft. long, which was packed with sandof various grain sizes. To date, only two kinds of sand have been packed inthis tube: 60 to 80-mesh Canadian river sand, 60 to 80-mesh and 80 to 100-meshSimpson sand. The original intention was to follow the same procedure and usethe same types of crude under identical saturation pressures of both air andgas, as well as unsaturated (dead) oil, flowing the various crudes throughseveral different sizes of both Canadian river and Simpson (Wilcox) sands, butlack of time has prevented such an intensive study of the problem.

Some additional time has been spent flowing saturated and unsaturated crudes, similar to those used in the 4-in. tube, through I-in. tubes, one of which was2 ft. long and one 5 ft. long. The results obtained have been checked againstthose obtained by using the 4-in. tube, to obtain the relation of diameter andlength of tube to rate of flow in similar sands.

Laboratory Equipment

Saturation Tank.-A heavy steel cylindrical saturation tank, capacity about 42gal. was mounted on a platform of bricks, then a galvanized tin temperaturebath was built around the saturation tank. This contained

* This paper contains results obtained in an investigation on The Effect ofNatural Gas on the Viscosity, Surface Tension, Adhesion and GeneralExtractability of Crude Oil, listed as Project No. 33 of American PetroleumInstitute Research. Financial assistance in this work has been received from aresearch fund of the American Petroleum Institute donated by John D.Rockefeller. This fund is being administered by the Institute with thecooperation of the Central Petroleum Committee of the National ResearchCouncil. Prof. H. C. George is Director of Project No. 33.