Efficacy Of Pharmacological Interventions Research Articles

Functional MRI to assess alterations of functional networks in response to pharmacological or genetic manipulations of the serotonergic system in mice

Imaging methods that enable the investigation of functional networks both in human and animal brain provide important insights into mechanisms underlying pathologies including psychiatric disorders. Since the serotonergic receptor 1A (5-HT(1A)-R) has been strongly implicated in the pathophysiology of depressive and anxiety disorders, as well as in the action of antidepressant drugs, we investigated brain connectivity related to the 5-HT(1A)-R system by use of pharmacological functional magnetic resonance imaging in mice. We characterized functional connectivity elicited by activation of 5-HT(1A)-R and investigated how pharmacological and genetic manipulations of its function may modulate the evoked connectivity. Functional connectivity elicited by administration of the 5-HT(1A)-R agonist 8-OH-DPAT can be described by networks characterized by small-world attributes with nodes displaying highly concerted response patterns. Circuits identified comprised the brain structures known to be involved in stress-related disorders (e.g. prefrontal cortex, amygdala and hippocampus). The results also highlight the dorsomedial thalamus, a structure associated with fear processing, as a hub of the 5-HT(1A)-R functional network. Administration of a specific 5-HT(1A)-R antagonist or use of heterozygous 5-HT(1A)-R knockout mice significantly reduced functional connectivity elicited by 8-OH-DPAT. Whole brain functional connectivity analysis constitutes an attractive tool to characterize impairments in neurotransmission and the efficacy of pharmacological treatment in a comprehensive manner.

2988 – The european psychiatric association (EPA) guidance on suicide treatment and prevention

Suicide is a major public health problem in the WHO European Region accounting for over 150,000 deaths per year. Suicidal crisis: Acute intervention should start immediately in order to keep the patient alive.An underlying psychiatric disorder is present in up to 90% of people who completed suicide. Comorbidity with depression, anxiety, substance abuse and personality disorders is high. In order to achieve successful prevention of suicidality, adequate diagnostic procedures and appropriate treatment for the underlying disorder are essential.Existing evidence supports the efficacy of pharmacological treatment and cognitive behavioural therapy (CBT) in preventing suicidal behaviour. Some other psychological treatments are promising, but the supporting evidence is currently insufficient. Studies show that antidepressant treatment decreases the risk for suicidality among depressed patients. However, the risk of suicidal behaviour in depressed patients treated with antidepressants exists during the first 10-14 days of treatment, which requires careful monitoring. Short-term supplementary medication with anxiolytics and hypnotics in the case of anxiety and insomnia is recommended. TREATMENT with antidepressants of children and adolescents should only be given under supervision of a specialist. Long-term treatment with lithium has been shown to be effective in preventing both suicide and attempted suicide in patients with unipolar and bipolar depression. TREATMENT with clozapine is effective in reducing suicidal behaviour in patients with schizophrenia. Other atypical antipsychotics are promising but more evidence is required. TREATMENT team: Multidisciplinary treatment teams including psychiatrist and other professionals such as psychologist, social worker, and occupational therapist are always preferable, as integration of pharmacological, psychological and social rehabilitation is recommended especially for patients with chronic suicidality. Family: The suicidal person independently of age should always be motivated to involve family in the treatment. Social support: Psychosocial treatment and support is recommended, as the majority of suicidal patients have problems with relationships, work, school and lack functioning social networks.A secure home, public and hospital environment, without access to suicidal means is a necessary strategy in suicide prevention. Each treatment option, prescription of medication and discharge of the patient from hospital should be carefully evaluated against the involved risks. Training of personnel: Training of general practitioners (GPs) is effective in the prevention of suicide. It improves treatment of depression and anxiety, quality of the provided care and attitudes towards suicide. Continuous training including discussions about ethical and legal issues is necessary for psychiatrists and other mental health professionals.

Effort-Based Reward (EBR) training enhances neurobiological efficiency in a problem-solving task: Insights for depression therapies

Effort-Based Reward (EBR) training strengthens associations between effort and rewards, leading to increased persistence in an unsolvable task when compared to control animals. EBR training involves placing animals in a test apparatus in which they are trained to dig in mounds to retrieve froot loop rewards (contingent group); these animals are compared to control animals that are given the same number of rewards, regardless of expended effort (noncontingent group). In the current study, the effect of EBR training on performance in a spatial task (Dry Land Maze) was explored to determine cognitive resilience during behavioral testing. Additionally, animals received BrdU injections during training to assess the role of neurogenesis on subsequent behavioral performance. Following the probe test, animals were perfused so that fos-immunoreactive (ir) cells in the hippocampus and cortical areas could be assessed. Behavioral results indicated that contingent rats were approximately 50% more efficient in locating and interacting with the previous baited well during the probe test than noncontingent animals, recruiting approximately 20% less c-fos ir-cells in the insular cortex, retrosplenial cortex, and dentate gyrus. A multidimensional scaling analysis grouped noncontingent animals together in a quadrant characterized by high latencies to find the previous baited well and higher ir-cell activation in the aforementioned areas. Thus, our data support the hypothesis that the EBR training enhances both cognitive functioning and emotional regulation during challenging events. Considering the ongoing controversy about the efficacy of pharmacological interventions in treating depression, the EBR model provides a valuable alternative for the investigation of the neurobiology of mood disorders.

Methylphenidate‐mediated reduction in prefrontal hemodynamic responses to working memory task: a functional near‐infrared spectroscopy study

Functional near-infrared spectroscopy (fNIRS) is a non-invasive optical technique for bedside evaluation of cerebral metabolism that has clinical potential for monitoring the efficacy of pharmacological treatment. In this pilot study, we investigated the cognitive effects of methylphenidate (MP) on prefrontal function using fNIRS in healthy subjects. Thirteen right-handed healthy subjects underwent working memory tasks (0-back and 2-back) after a single oral dose of MP (20 mg) or placebo administered in a double-blind crossover design on two different days separated by 1-3 days. We measured changes in oxyhemoglobin (oxy-Hb) and deoxyhemoglobin (deoxy-Hb) concentrations during the tasks in bilateral prefrontal regions after MP or placebo administration using two-channel fNIRS. There were significantly more correct responses and fewer missed responses during the 2-back task performance after MP treatment as compared with placebo. Baseline-corrected oxy-Hb was significantly decreased after MP treatment compared with the placebo in the 2-back task in the right frontal region but was not different in the 0-back task. Baseline-corrected deoxy-Hb and total-Hb concentrations were not significant between MP and placebo conditions in either of the cognitive tasks. These data are consistent with previous positron emission tomography findings of MP-mediated reduction in lateral prefrontal activity accompanied by improved cognitive performance.

Pain Adversely Affects Outcomes to a Collaborative Care Intervention for Anxiety in Primary Care

Primary care patients with Panic Disorder (PD) and Generalized Anxiety Disorder (GAD) experience poorer than expected clinical outcomes, despite the availability of efficacious pharmacologic and non-pharmacologic treatments. A barrier to recovery from PD/GAD may be the co-occurrence of pain. To evaluate whether pain intensity interfered with treatment response for PD and/or GAD in primary care patients who had received collaborative care for anxiety disorders. A secondary data analysis of a randomized, controlled effectiveness trial comparing a telephone-delivered collaborative care intervention for primary care patients with severe PD and/or GAD to their doctor's "usual" care. Patients had to have a diagnosis of PD and/or GAD and a severe level of anxiety symptoms. The 124 patients randomized at baseline to the collaborative care intervention were analyzed. Participants were divided into two pain intensity groups based on their response to the SF-36 Bodily Pain scale (none or mild pain vs. at least moderate pain). Pain was assessed using the Bodily Pain scale of the SF-36. Anxiety symptoms were measured with the Hamilton Anxiety Rating Scale (HRS-A), Panic Disorder Severity Scale (PDSS) and Generalized Anxiety Disorder Severity Scale (GADSS). Measures were collected over 12 months. At baseline, patients with at least moderate pain were significantly more likely to endorse more anxiety symptoms on the HRS-A than patients with no pain or mild pain (P < .001). Among patients with severe anxiety symptoms, 65 % (80/124) endorsed experiencing at least moderate pain in the previous month. A significantly lesser number of patients achieved a 50 % improvement at 12 months on the HRS-A and GADSS if they had at least moderate pain as compared to patients with little or no pain (P = 0.01 and P = 0.04, respectively). Coexisting pain was common in a sample of primary care patients with severe PD/GAD, and appeared to negatively affect response to anxiety treatment.

Treatments for anxiety and depression in patients with chronic obstructive pulmonary disease: A literature review

Chronic obstructive pulmonary disease (COPD) is a serious contemporary health issue. Psychological co-morbidities such as anxiety and depression are common in COPD. Current evidence for treatment options to reduce anxiety and depression in patients with COPD was examined. There is evidence available for the efficacy of pharmacological treatments, cognitive behavioural therapy, pulmonary rehabilitation, relaxation therapy and palliative care in COPD. Therapeutic modalities that have not been proven effective in decreasing anxiety and depression in COPD, but which have theoretical potential among patients, include interpersonal psychotherapy, self-management programmes, more extensive disease management programmes, supportive therapy and self-help groups. Besides pulmonary rehabilitation that is only available for a small percentage of patients, management guidelines make scant reference to other options for the treatment of mental health problems. The quantity and quality of research on mental health treatments in COPD have historically been insufficient to support their inclusion in COPD treatment guidelines. In this review, recommendations regarding assessment, treatment and future research in this important field were made.

Pharmacotherapy for premenstrual dysphoric disorder: A meta-analysis of phase 3 trials

Premenstrual dysphoric disorder (PMDD) is a common condition that temporarily, but repetitively affects patient’s global function. Patients and physicians alike are often uncertain whether prescription medication for PMDD is suffi ciently effective. The prima ry objective of this analysis is signal detection in effi cacy of pharmacological treatments in PMDD. Secondary objective is to rev iew which symptoms are likely to respond to which medications. The review included otherwise healthy women with clinician confi rmed diagnosis of PMDD who participated in phase 3 clinical trials for the treatment of PMDD. Twelve pair-wise comparisons of drug and placebo for 2,420 patients with PMDD were performed. Oral contraceptives and selective serotonin receptor inhibitor were effective in alleviating symptoms of PMDD compared to placebo. Both Intermittent and continuous administration were more effective than placebo. This meta-analysis provides a signal that pharmacological treatment of PMDD is effective.

The Efficacy of Pharmacological Treatment in Pediatric Nonalcoholic Fatty Liver Disease

PurposeWith growing number of obese children, the prevalence of nonalcoholic fatty liver disease (NAFLD) in pediatric population is increasing. Nonalcoholic steatohepatitis (NASH) is a severe form of NAFLD, and can cause morbid complications. It is important to identify patients in order to grade pathologic severities and treat those children who possibly have NASH. This study was performed to evaluate whether the pharmacological therapy is also effective as well as the body weight reduction in pediatric NAFLD.MethodsAmong the 52 children presenting with obesity and hepatopathy, NAFLD was diagnosed through liver biopsy in 29 children, who were 7 to 14 years of age, from January 2006 to December 2011. The patients were advised to reduce their body weight through diverse methods. Medication with Ursodeoxycholic acid (UDCA) and vitamin E was performed in children whose liver functions did not improve or their weight reductions were not successful. The therapeutic effects were monitored and assessed via the biochemical profiles and the physical measurements.ResultsThe therapy of vitamin E and UDCA combined with body mass index (BMI) reduction showed significantly higher rate of improvement in clinical profiles, which could be seen in data of aspartate aminotransferase (AST), alanine aminotransferase (ALT), AST/ALT ratio, alkaline phosphatase, total bilirubin and γ-glutamyl transpeptidase. Children whose BMI were successfully reduced showed favorable clinical improvements without any medication, but those without BMI reduction did not show any improvement despite medications.ConclusionThis study showed that the first line of therapy should be the BMI reduction in NAFLD and drug therapy combined with BMI reduction could have additive therapeutic effect in children with NAFLD.

Obstetric complications and pregnancy-related venous thromboembolism: The effect of low-molecular-weight heparin on their prevention in carriers of factor V Leiden or prothrombin G20210A mutation

Whether the administration of low-molecular-weight heparin (LMWH) during pregnancy is effective in preventing obstetric complications and pregnancy-related venous thromboembolism (VTE) in women who are carriers of factor V Leiden (FVL) and/or prothrombin variant G20210A (PTm) is controversial. This observational study investigated the possible efficacy of pharmacological treatment with LMWH ± aspirin (ASA) in pregnancy outcomes in 1,011 pregnancies of 416 women with thrombophilia (FVL and/or PTm). Most patients were chosen on the basis of previous obstetrical complications (36%), or because of familial or personal history of venous/arterial thromboembolism (28% and 18%, respectively); 74 patients (18%) were incidentally identified. The outcome was evaluated according to the type of treatment and of the period of pregnancy when the treatment was started. After adjustment for observation before and after diagnosis of thrombophilia, previous miscarriages and VTE, parity, age and centre, we observed that LMWH had a protective effect on miscarriages (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.29-0.94) and VTE (OR 0.05, 95% CI 0.01-0.21). ASA appeared to have no effect on the prevention of obstetric complications and VTE. A nested analysis performed in 116 women with two or more obstetric complications confirmed that the highest number of live births was recorded in the group under LMWH prophylaxis (OR 0.19, 95% CI 0.05-0.75). These results suggest that LMWH prophylaxis reduces the risk of obstetric complications in carriers of FVL and/or PTm, particularly in those with previous obstetric events. Furthermore, LMWH prophylaxis reduces the risk of pregnancy-related VTE.

Functional Brain Imaging of Tobacco Exposure in Humans

Cigarette smoking represents a major health problem in the United States. Although most cigarette smokers express a desire to quit, only about 14 to 49% will be successful after 6 or more months of treatment. An improved understanding of the acute and chronic effects of smoking on brain function may lead to more efficacious pharmacological and behavioral treatments for smoking dependence. Many research groups have utilized functional brain imaging to examine the effects of tobacco exposure on brain activity. Acute administration of nicotine and cigarette smoking itself have been found to increase activity in the prefrontal cortex, thalamus, and visual system; reduce global brain activity; and increase dopamine (DA) release in the ventral striatum/nucleus accumbens. Chronic tobacco exposure lead to an overall up-regulation of α4β2 nicotinic acetylcholine receptors (nAChRs) across brain regions (other than thalamus), and reduced monoamine oxidase (MAO) A and B levels in the basal ganglia. Functional brain imaging studies of cigarette craving and withdrawal, too, demonstrate important changes in brain activity. Taken together, current research suggests that smoking enhances neurotransmission through cortico-basal ganglia-thalamic circuits by either direct stimulation of nAChRs, indirect stimulation through DA release of MAO inhibition, or a combination of these, and perhaps, other factors. The purpose of this review is to provide a summary of current functional brain imaging studies of tobacco use and dependence, and use this information to develop a greater understanding of brain function in smokers.

The European Psychiatric Association (EPA) guidance on suicide treatment and prevention

Suicide is a major public health problem in the WHO European Region accounting for over 150,000 deaths per year. Suicidal crisisAcute intervention should start immediately in order to keep the patient alive. DiagnosisAn underlying psychiatric disorder is present in up to 90% of people who completed suicide. Comorbidity with depression, anxiety, substance abuse and personality disorders is high. In order to achieve successful prevention of suicidality, adequate diagnostic procedures and appropriate treatment for the underlying disorder are essential. TreatmentExisting evidence supports the efficacy of pharmacological treatment and cognitive behavioural therapy (CBT) in preventing suicidal behaviour. Some other psychological treatments are promising, but the supporting evidence is currently insufficient. Studies show that antidepressant treatment decreases the risk for suicidality among depressed patients. However, the risk of suicidal behaviour in depressed patients treated with antidepressants exists during the first 10–14 days of treatment, which requires careful monitoring. Short-term supplementary medication with anxiolytics and hypnotics in the case of anxiety and insomnia is recommended. Treatment with antidepressants of children and adolescents should only be given under supervision of a specialist. Long-term treatment with lithium has been shown to be effective in preventing both suicide and attempted suicide in patients with unipolar and bipolar depression. Treatment with clozapine is effective in reducing suicidal behaviour in patients with schizophrenia. Other atypical antipsychotics are promising but more evidence is required. Treatment teamMultidisciplinary treatment teams including psychiatrist and other professionals such as psychologist, social worker, and occupational therapist are always preferable, as integration of pharmacological, psychological and social rehabilitation is recommended especially for patients with chronic suicidality. FamilyThe suicidal person independently of age should always be motivated to involve family in the treatment. Social supportPsychosocial treatment and support is recommended, as the majority of suicidal patients have problems with relationships, work, school and lack functioning social networks. SafetyA secure home, public and hospital environment, without access to suicidal means is a necessary strategy in suicide prevention. Each treatment option, prescription of medication and discharge of the patient from hospital should be carefully evaluated against the involved risks. Training of personnelTraining of general practitioners (GPs) is effective in the prevention of suicide. It improves treatment of depression and anxiety, quality of the provided care and attitudes towards suicide. Continuous training including discussions about ethical and legal issues is necessary for psychiatrists and other mental health professionals.

Antipsychotics, Antidepressants, Anticonvulsants, and Placebo on the Symptom Dimensions of Borderline Personality Disorder

The aim of this study was to quantitatively review randomized controlled trials (RCTs) and open-label trials analyzing the efficacy of antidepressants, mood stabilizers, and antipsychotics for the treatment of the core symptoms of borderline personality disorder (BPD). Using a similar meta-analytic approach, the efficacy of placebo on the same core symptoms of BPD was evaluated. The risk of discontinuation of each of the medication classes reported in the studies was also analyzed to establish the major causes of discontinuation. MEDLINE (1966 to June 2010) and EMBASE (1980 to June 2010) databases were systematically searched to identify relevant RCTs and open studies. The primary outcome was improvement in the specific core symptoms of the disorder: affective dysregulation, impulsive-behavioral dyscontrol, and cognitive-perceptual symptoms. Evidence from RCTs and open studies suggests that drug treatment, especially with mood stabilizers and antipsychotics, may be effective for treating affective dysregulation and impulsive-behavioral dyscontrol. Antipsychotics were also effective in reducing cognitive-perceptual symptoms. Antidepressants failed to show efficacy in treating BPD symptom dimensions other than affective dysregulation. Our analyses of the placebo arm of RCTs showed a significant improvement of symptomatology in these patients also. There were no significant differences in overall dropout rates between patients on medications and those on placebo. In conclusion, the efficacy of pharmacological treatment on the symptom dimensions of BPD has been shown by various independent meta-analyses, with a positive effect of drug treatment on the core symptoms of BPD and some documentable differences in terms of efficacy between different drug classes in each of the symptom domains.

Editorial [Hot Topic: Bringing Drugs Into the Injured Brain and Keeping Them There (Executive Guest Editors: Dirk M. Hermann and Pauline Patak)

The delivery of pharmacological compounds to the injured brain is a huge challenge, which may predispose to drug failure and resistance. Besides the limited passage of drugs across the blood-brain barrier, which is a physical obstacle for the majority of pharmacological compounds, brain capillary cells express ATP-binding cassette (ABC) transporters on their surface, which actively remove drugs from the brain against concentration gradients. Eliminating a large number of pharmacological compounds and endogenous substrates from the brain tissue, ABC transporters play a major role for the maintenance of brain homeostasis and detoxification. The present issue summarizes current knowledge on ABC transporters in the injured brain, outlining how these efflux systems are regulated under pathological conditions, how they impede the brain accumulation of drugs and how they might contribute to the pathogenesis of neurological diseases once they become dysfunctional. This issue analyzes the validity of the concept of multidrug resistance, evaluating how ABC transporters may be modified in order to enable the development of more efficacious pharmacological treatments.

A Systematic Review and Mixed Treatment Comparison of the Efficacy of Pharmacological Treatments for Fibromyalgia

To review the literature on pharmacological treatments for fibromyalgia. Relative efficacy was estimated in terms of outcome measures highlighted by the Outcome Measures in Rheumatology Network using a Bayesian mixed treatment comparison (MTC) meta-analysis. Randomized controlled trials reporting treatments for fibromyalgia were identified by systematically reviewing electronic databases (Cochrane Library, Medline, EMBASE; accessed February 2008) and conducting manual bibliographic searches. Forty-five randomized controlled trials met the prespecified inclusion criteria for the systematic review. There were limited robust clinical data for some therapeutic classes (tricyclic antidepressants, analgesics, sedative hypnotics, monoamine oxidase inhibitors) and only 21 studies met the more stringent criteria for inclusion in the MTC. The majority of studies included in the MTC assessed the anticonvulsant pregabalin (n = 5) or the serotonin norepinephrine reuptake inhibitors (SNRIs) duloxetine (n = 3) and milnacipran (n = 3). Licensed doses of pregabalin and duloxetine were significantly (P < 0.05) more efficacious than placebo in terms of absolute reduction in pain, number of "responders" (≥30% reduction in pain), or change in Fibromyalgia Impact Questionnaire score (pregabalin 450 mg/d only). There was no significant difference between licensed doses of pregabalin and duloxetine for these outcomes. However licensed doses of pregabalin produced significantly greater improvements in sleep compared with milnacipran (as measured by Medical Outcomes Study Sleep Scale). The current study confirms the therapeutic efficacy of pregabalin and the SNRIs, duloxetine and milnacipran, in the treatment of fibromyalgia. Given their different modes of action, combination therapy with pregabalin plus an SNRI should be investigated in future research.

Comparative efficacy and acceptability of antimanic drugs in acute mania: a multiple-treatments meta-analysis

Conventional meta-analyses have shown inconsistent results for efficacy of pharmacological treatments for acute mania. We did a multiple-treatments meta-analysis, which accounted for both direct and indirect comparisons, to assess the effects of all antimanic drugs. We systematically reviewed 68 randomised controlled trials (16,073 participants) from Jan 1, 1980, to Nov 25, 2010, which compared any of the following pharmacological drugs at therapeutic dose range for the treatment of acute mania in adults: aripiprazole, asenapine, carbamazepine, valproate, gabapentin, haloperidol, lamotrigine, lithium, olanzapine, quetiapine, risperidone, topiramate, and ziprasidone. The main outcomes were the mean change on mania rating scales and the number of patients who dropped out of the allocated treatment at 3 weeks. Analysis was done by intention to treat. Haloperidol (standardised mean difference [SMD] -0·56 [95% CI -0·69 to -0·43]), risperidone (-0·50 [-0·63 to -0·38), olanzapine (-0·43 [-0·54 to -0·32], lithium (-0·37 [-0·63 to -0·11]), quetiapine (-0·37 [-0·51 to -0·23]), aripiprazole (-0·37 [-0·51 to -0·23]), carbamazepine (-0·36 [-0·60 to -0·11], asenapine (-0·30 [-0·53 to -0·07]), valproate (-0·20 [-0·37 to -0·04]), and ziprasidone (-0·20 [-0·37 to -0·03]) were significantly more effective than placebo, whereas gabapentin, lamotrigine, and topiramate were not. Haloperidol had the highest number of significant differences and was significantly more effective than lithium (SMD -0·19 [95% CI -0·36 to -0·01]), quetiapine (-0·19 [-0·37 to 0·01]), aripiprazole (-0·19 [-0·36 to -0·02]), carbamazepine (-0·20 [-0·36 to -0·01]), asenapine (-0·26 [-0·52 to 0·01]), valproate (-0·36 [-0·56 to -0·15]), ziprasidone -0·36 [-0·56 to -0·15]), lamotrigine (-0·48 [-0·77 to -0·19]), topiramate (-0·63 [-0·84 to -0·43]), and gabapentin (-0·88 [-1·40 to -0·36]). Risperidone and olanzapine had a very similar profile of comparative efficacy, being more effective than valproate, ziprasidone, lamotrigine, topiramate, and gabapentin. Olanzapine, risperidone, and quetiapine led to significantly fewer discontinuations than did lithium, lamotrigine, placebo, topiramate, and gabapentin. Overall, antipsychotic drugs were significantly more effective than mood stabilisers. Risperidone, olanzapine, and haloperidol should be considered as among the best of the available options for the treatment of manic episodes. These results should be considered in the development of clinical practice guidelines. None.

Group Releases New Guideline on Options for Treating Painful Diabetic Neuropathy

A NEW GUIDELINE FOR USING EFfective therapies for patients with painful diabetic neuropathy has been issued by the American Academy of Neurology. The guideline, released in April, was established through a systematic review of the literature from 1960 to August 2008 that reported on the efficacy of pharmacological treatments (such as anticonvulsants, antidepressants, and opioids) and nonpharmacological treatments (such as electrical stimulation, magnetic field treatment, low-intensity laser treatment, and Reiki massage). The guideline authors rated the therapies based on the quality of the evidence (Bril V et al. Neurology. 2011; 76[20]:1758-1765). The burning or tingling pain of diabetic neuropathy adversely affects patients’ quality of life. It is estimated that about 16% of patients with diabetes have painful diabetic neuropathy. And while treatments are available, an estimated 39% of cases remain untreated and about 1 in 8 patients do not even report the condition to their physicians. Vera Bril, MD, the lead guideline author and director of the neuromuscular section of the University of Toronto in Toronto, Ontario, Canada, explained why the academy decided to publish the guideline. “We did it because there are new treatments available and people are all over the place in thinking of what works and does not work,” Bril said. What works, at least according to the most rigorous study, is the anticonvulsant pregabalin, which the authors said is effective in lessening the pain of diabetic neuropathy and in improving quality of life; the drug also lessens sleep interference, although the effect size is small. Pregabalin was the only treatment to receive the more rigorous level A recommendation by the authors.

Efficacy and tolerance of systemic steroids in sciatica: a systematic review and meta-analysis

The efficacy of pharmacological interventions in sciatica is limited and the use of systemic steroids is still controversial. We aimed at evaluating the efficacy and tolerance of systemic steroids in sciatica. A systematic literature search was performed in the Medline, Embase and Cochrane databases until February 2010. Randomized placebo-controlled trials evaluating the efficacy and the tolerance of systemic steroids in sciatica were included. Efficacy and tolerance were assessed using the relative risk (RR) and 95% CI with the inverse variance method (RR > 1 means that the event is more likely to occur in the steroid group). We explored the heterogeneity between the studies using subgroup analysis. Seven studies (383 patients) were included. The difference in the rate of responders between both groups was not statistically significant (RR = 1.22, 95% CI 0.96, 1.56). The rate of adverse events was 13.3% for the patients in the steroid group and 6.6% for the placebo group (RR = 2.01, 95% CI 1.06, 3.80). The number needed to harm was 20 (95% CI 10, ∞). Twenty (15.3%) patients in the steroid group and seven (5.7%) patients in the placebo group underwent surgery. A trend towards a higher requirement for spinal surgery was observed in the steroid group (RR = 1.14, 95% CI 0.74, 1.75). The methodological quality slightly influenced the results. We did not find any publication bias. Steroid efficacy is not superior to the placebo in sciatica, but it has more side effects. The tolerance : efficacy ratio indicates against the use of systemic steroids in sciatica.

A cognitive-behavioral treatment for irritable bowel syndrome using interoceptive exposure to visceral sensations

BackgroundIrritable bowel syndrome (IBS) is a chronic and debilitating medical condition with few efficacious pharmacological or psychosocial treatment options available. Evidence suggests that visceral anxiety may be implicated in IBS onset and severity. Thus, cognitive-behavioral treatment (CBT) that targets visceral anxiety may alleviate IBS symptoms. MethodsThe current study examined the efficacy of a CBT protocol for the treatment of IBS which directly targeted visceral sensations. Participants (N = 110) were randomized to receive 10 sessions of either: (a) CBT with interoceptive exposure (IE) to visceral sensations; (b) stress management (SM); or (c) an attention control (AC), and were assessed at baseline, mid-treatment, post-treatment, and follow-up sessions. ResultsConsistent with hypotheses, the IE group outperformed AC on several indices of outcome, and outperformed SM in some domains. No differences were observed between SM and AC. The results suggest that IE may be a particularly efficacious treatment for IBS. ConclusionsImplications for research and clinical practice are discussed.

Efficacy of pharmacological treatment and genetic characterization in early diagnosed patients affected by long QT syndrome with impaired AV conduction

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Pharmacological treatment of sex offenders

Summary Sex offending is a major public health concern due to the potentially serious consequences for the victims (especially in case of rape or paedophilia). All care providers agree that imprisonment alone does not solve the question of repeat offences for these subjects and that a combined medical, psychological and social approach is needed for these offenders. A combination of psychotherapy (especially behavioral therapy) with pharmacological treatment is better than one or other therapy used alone. Two types of medication are used for these subjects; serotonergic antidepressants and antiandrogen treatments. Two antiandrogen treatments have obtained Health Agency approval in different European countries in this indication: cyproterone acetate and depot triptorelin (3-month formulation). Guidelines have been published in France by the National Health Authority and, at the international level, by the World Federation of Societies of Biological Psychiatry ( www.wfsbp.org ). In this paper, we will define the term paraphilia and report some epidemiological data, before summarizing the available literature about the efficacy of pharmacological treatment for paraphilias.