Use Of Tricyclic Antidepressants Research Articles

Predictors of suboptimal bowel preparation in asymptomatic patients undergoing average-risk screening colonoscopy.

To identify risk factors for a suboptimal preparation among a population undergoing screening or surveillance colonoscopy. Retrospective review of the University of Michigan and Veteran's Administration (VA) Hospital records from 2009 to identify patients age 50 and older who underwent screening or surveillance procedure and had resection of polyps less than 1 cm in size and no more than 2 polyps. Patients with inflammatory bowel disease or a family history of colorectal cancer were excluded. Suboptimal procedures were defined as procedure preparations categorized as fair, poor or inadequate by the endoscopist. Multivariable logistic regression was used to identify predictors of suboptimal preparation. Of 4427 colonoscopies reviewed, 2401 met our inclusion criteria and were analyzed. Of our population, 16% had a suboptimal preparation. African Americans were 70% more likely to have a suboptimal preparation (95%CI: 1.2-2.4). Univariable analysis revealed that narcotic and tricyclic antidepressants (TCA) use, diabetes, prep type, site (VA vs non-VA), and presence of a gastroenterology (GI) fellow were associated with suboptimal prep quality. In a multivariable model controlling for gender, age, ethnicity, procedure site and presence of a GI fellow, diabetes [odds ratio (OR) = 2.3; 95%CI: 1.6-3.2], TCA use (OR = 2.5; 95%CI: 1.3-4.9), narcotic use (OR = 1.7; 95%CI: 1.2-2.5) and Miralax-Gatorade prep vs 4L polyethylene glycol 3350 (OR = 0.6; 95%CI: 0.4-0.9) were associated with a suboptimal prep quality. Diabetes, narcotics use and TCA use were identified as predictors of poor preparation in screening colonoscopies while Miralax-Gatorade preps were associated with better bowel preparation.

An observational study of the effect of escitalopram and etizolam in type 2 diabetes mellitus patients with depression

Background: Past decades have witnessed a rapid rise in the prevalence of diabetes mellitus; estimated to affect 415 million adults worldwide and 69.1 million adults in India. There has been an increased prevalence of diabetes associated depression, which can aggravate the symptoms of depression and diabetes associated complications. Use of tricyclic antidepressants (TCA) can disturb the glycemic control. Escitalopram is a selective serotonin reuptake inhibitor (SSRI) and Etizolam is a new safe antianxiety agent. The objective of this study was to study the prevalence of depression and anxiety in type 2 diabetes mellitus patients and to assess the efficacy of escitalopram and etizolam in the treatment of depression and/or anxiety in type 2 diabetes mellitus patients. Methods: Total 125 patients diagnosed with type 2 diabetes mellitus with fulfilling the inclusion and exclusion criteria were included in the study. Informed written consent was obtained from the patients willing to participate in the study. They were screened for the presence of depression with the help of PHQ-9. Their demographic features were recorded and initial laboratory investigations done. Haemogram, blood sugar level - fasting (BSL-F) and postprandial (PP), serum alanine transferase (ALT), serum creatinine and Urine routine analysis. Patients were started on Escitalopram (10 mg) + Etizolam (0.5 mg) daily for 30 days and others were not treated and acted as control; keeping the management of diabetes mellitus unchanged for all. Laboratory investigations were repeated after 30 days. Results: The prevalence of depression with/without anxiety was 35.2%. 51 patients treated with Escitalopram + Etizolam improved clinically and biochemically. There was a significant (P < 0.05) improvement in BSL-F and PP and HbA1C in patients treated with Escitalopram + Etizolam. Conclusions: Prevalence of depression among type 2 diabetes mellitus was found to be 35% in this study. Fifty one patients treated with escitalopram + etizolam improved clinically as well as biochemically. There was significant improvement in BSL-F, BSL-PP and HbA1c. Escitalopram may be considered as antidepressant of choice in such cases.

Neuromodulation in the Management of Allergic Chronic Vaginitis

Chronic vaginitis (CV) affects 16% of women. While a number of distinct diagnoses account for the underlying causes of CV, allergic inflammation is also present in a significant number of cases and may range from 25 to 54% of CV patients. Allergic inflammation in CV is encountered as a result of: i) direct sensitization of the vaginal mucosa to latex, local products, Candida, bacteria, etc.; ii) inhalant allergy compounding the chronic vaginitis syndrome; iii) immune cell activation secondary to neurogenic inflammation in the context of chronic neuropathic pain. Despite the varying nature of specific neuro-immune interactions, chronic pain/irritation remains a cardinal feature of CV which needs to be addressed as a priority independently of specific gynecological or allergy-modifying interventions. This is necessary not only for reasons of symptom relief but also because long-term neuronal changes due to inflammation and chronic pain have a profound effect on the course of CV by potentiating adverse pro-inflammatory and degenerating processes. The pathophysiology of these processes and their alteration by means of neuromodulators is presented with a view of long-term control of chronic pain and neurogenic inflammation. Special emphasis is placed on gamma-aminobutyric acid-served pathways, the use of tricyclic antidepressants, serotoninreuptake inhibitors and certain antihistamines with anti-serotoninergic properties.

Risk of Seizures Associated with Antidepressant Use in Patients with Depressive Disorder: Follow-up Study with a Nested Case-Control Analysis Using the Clinical Practice Research Datalink.

Antidepressant use has been associated with an increased risk of seizures. Evidence on the association between antidepressant use at therapeutic doses and seizures mainly comes from clinical trials that were not designed to investigate this potential relationship. The objective of this study was to assess the risk of first-time seizures in association with exposure to antidepressants in patients with depressive disorders. We conducted a retrospective follow-up study with a nested case-control analysis between 1998 and 2012, using data from the UK-based Clinical Practice Research Datalink (CPRD). We estimated crude incidence rates with 95 % confidence intervals (CIs) of seizures in depressed patients who used selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), 'other antidepressants', no antidepressants, or who had used antidepressants in the past. To adjust for potential confounding, we estimated odds ratios of antidepressant drug use among cases with seizures and matched controls in a nested case-control analysis. Of 151,005 depressed patients, 619 had an incident seizure during follow-up. Incidence rates per 10,000 person-years were 12.44 (95 % CI 10.67-14.21) in SSRI users, 15.44 (95 % CI 8.99-21.89) in SNRI users, 8.33 (95 % CI 4.68-11.98) in TCA users, 9.33 (95 % CI 6.19-12.46) in non-users of antidepressants, and 5.05 (95 % CI 4.49-5.62) in past users of antidepressants. In the case-control analysis, relative risk estimates for seizures were increased in current users of SSRIs (adjusted odds ratio 1.98, 95 % CI 1.48-2.66) and SNRIs (adjusted odds ratio 1.99, 95 % CI 1.20-3.29), but not TCAs (adjusted odds ratio 0.99, 95 % CI 0.63-1.53), compared with non-users. Current use of SSRIs or SNRIs was associated with a twofold increased risk of first-time seizures compared with non-use, while current use of TCAs (mostly low dose) was not associated with seizures. Treatment initiation in SSRI and SNRI users was associated with a higher risk of seizures than longer-term treatment.

Distal Symmetric Polyneuropathy: A Review.

Peripheral neuropathy is a highly prevalent and morbid condition affecting 2% to 7% of the population. Patients frequently experience pain and are at risk of falls, ulcerations, and amputations. We aimed to review recent diagnostic and therapeutic advances in distal symmetric polyneuropathy, the most common subtype of peripheral neuropathy. Current evidence supports limited routine laboratory testing in patients with distal symmetric polyneuropathy. Patients without a known cause should undergo a complete blood cell count, comprehensive metabolic panel, vitamin B12 measurement, serum protein electrophoresis with immunofixation, fasting glucose measurement, and glucose tolerance test. The presence of atypical features such as asymmetry, non-length dependence, motor predominance, acute or subacute onset, and prominent autonomic involvement should prompt a consultation with a neurologist or neuromuscular specialist. Electrodiagnostic tests and magnetic resonance imaging of the neuroaxis contribute substantial cost to the diagnostic evaluation, but evidence supporting their use is lacking. Strong evidence supports the use of tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, and voltage-gated calcium channel ligands in the treatment of neuropathic pain. More intensive glucose control substantially reduces the incidence of distal symmetric polyneuropathy in patients with type 1 diabetes but not in those with type 2 diabetes. The opportunity exists to improve guideline-concordant testing in patients with distal symmetric polyneuropathy. Moreover, the role of electrodiagnostic tests needs to be further defined, and interventions to reduce magnetic resonance imaging use in this population are needed. Even though several efficacious medications exist for neuropathic pain treatment, pain is still underrecognized and undertreated. New disease-modifying medications are needed to prevent and treat peripheral neuropathy, particularly in type 2 diabetes.

Urinary Retention After Hysterectomy and Postoperative Analgesic Use.

This study aimed to determine risk factors, including postoperative analgesic use, for the development of postoperative urinary retention (PUR) after hysterectomy for routine gynecologic indications using a case-control study design. Cases of PUR after hysterectomy were identified from billing data. Cases were those patients requiring recatheterization for inability to void. Controls were similarly identified and matched by age and date of surgery in a 3:1 control-to-case ratio. Chart review was performed to obtain demographic, medical, surgical, anesthetic, and medication data. Cumulative and interval doses of postoperative narcotic were recorded and converted into morphine equivalents. Crude odds ratios (ORs) were determined for potential risk factors for PUR using standard statistical analysis. Conditional logistic regression was used on multivariate models, including cumulative postoperative narcotic use, to determine adjusted ORs for risk factors. Twenty-six cases of PUR were matched with 78 controls. The cases had a higher body mass index (32 vs 28 kg/m2, P = 0.02), had a higher preoperative use of tricyclic antidepressants (TCA; 19.2% vs 1.3%, P = 0.004), were more likely to present preoperative urinary retention associated with fibroids (19.2% vs 0%, P < 0.01), and received a higher cumulative narcotic dose in the postoperative period (109 vs 73.6 mg, P < 0.001). In a multivariate model, preoperative TCA use (OR, 30.1; 95% confidence interval, 1.99-456; P = 0.01) and cumulative narcotic dose (OR, 2.54; 95% confidence interval, 1.44-4.56; P < 0.01) were significantly associated with PUR. Postoperative urinary retention after hysterectomy is associated with higher postoperative narcotic dose, preoperative TCA use, and preoperative urinary retention.

Consensus Validated List of Potentially Inappropriate Medication for the Elderly and Their Prevalence in South Korea

Summary Background The aims of this study were to generate a comprehensive potentially inappropriate medication (PIM) list applicable for Korean elderly based on the international PIM lists (Beers, Screening Tool for Older Person's Prescriptions, and PRISCUS), and to determine the PIM prevalence rate in the elderly who utilized long-term care services. Methods We generated a list of drug ingredients included in all the three criteria, and also the current Korean national formulary list. Twenty-six drug ingredients belonging to seven drug classes were finally selected. A two-round Delphi survey consisting of 20 experts was conducted to make a consensus on the PIM criteria applicable to Korean elderly. Individual questions regarding PIM criteria were answered using a 5-point Likert scale. The PIM prevalence rate in elderly was analyzed using the National Health Insurance claims data and the Long-term Care Benefit claims data over a 6-month period (from July 2011 to December 2011). Results All 26 drug ingredients were determined to be PIMs for Korean elderly. The prevalence rate of PIM in elderly under long-term care was 41.4% (98,158/237,285 individuals). Benzodiazepines were the most prevalent PIM drug class (28.9%), followed by first generation antihistamines (26.9%). The use of nonsteroidal anti-inflammatory drugs and tricyclic antidepressants were 9.3% and 6.4% of total individuals, respectively. Conclusion The comprehensive PIM list may be helpful for clinical practitioners to optimize drug choices for their elderly patients. A relatively high PIM prevalence in the elderly suggests that efficient strategies should be designed to reduce PIM in elderly populations in long-term care settings.

Antidepressant use and risk of recurrent stroke: a population-based nested case-control study.

Antidepressants may carry an increased risk for incident stroke, but there is little safety evidence regarding poststroke antidepressant use. This study aimed to examine whether antidepressants are associated with an increased risk of stroke recurrence. A population-based nested case-control study was conducted analyzing the Taiwan universal health care claims database from January 1, 2000, to December 31, 2008. We followed up 19,825 patients who survived a first admission for stroke at the age of ≥ 18 years, among which 3,536 hospitalized cases with stroke recurrence (ICD-9-CM codes 430.xx-437.xx) were identified and individually matched to 6,679 randomly-selected controls. Multivariate conditional logistic regression models were used to characterize the risk associated with antidepressant use. The study cohort had a mean age of 66 years and was followed up for a median of 2.9 person-years. Use of any tricyclic antidepressants (TCAs) was associated with a 1.41-fold (95% CI, 1.19-1.67) increased risk of stroke recurrence, whereas any use of selective serotonin reuptake inhibitors (SSRIs) or other antidepressants showed no association. Stopping TCAs for 1-30 days was associated with a 1.87-fold (95% CI, 1.22-2.86) increased risk of stroke recurrence, and the risk was attenuated for a longer discontinuation. The stroke risk associated with TCA use was not present in a dose-dependent or duration-dependent manner. Use of TCAs, but not SSRIs or other antidepressants, was associated with an increased risk of stroke recurrence. The risk is particularly elevated with abrupt cessation of TCA therapy. Health care professionals should be vigilant to that risk during TCA therapy in poststroke patients.

Predictors of Inadequate Inpatient Colonoscopy Preparation and Its Association with Hospital Length of Stay and Costs.

Adequate bowel preparation is essential to safe and effective inpatient colonoscopy. Predictors of poor inpatient colonoscopy preparation and the economic impacts of inadequate inpatient preparations are not defined. The aims of this study were to (1) determine risk factors for inadequate inpatient bowel preparations, and (2) examine the association between inadequate inpatient bowel preparation and hospital length of stay (LOS) and costs. We performed a retrospective cohort study of adult patients undergoing inpatient colonoscopy preparation over 12 months (1/1/2013-12/31/2013). Of 524 identified patients, 22.3% had an inadequate preparation. A multiple logistic regression model identified the following potential predictors of inadequate bowel preparation: lower income (OR 1.11; 95% CI 1.04, 1.22), opiate or tricyclic antidepressant (TCA) use (OR 1.55; 0.98, 2.46), and afternoon colonoscopy (OR 1.66; 1.07, 2.59); as well as American Society of Anesthesiologists (ASA) class ≥3 (OR 1.15; 1.05, 1.25) and symptoms of nausea/vomiting (OR 1.14; 1.04, 1.25) when a fair preparation was considered inadequate. Inadequate bowel preparation was associated with significantly increased hospital LOS (model relative mean estimate 1.25; 95% CI 1.03, 1.51) and hospital costs (estimate 1.31; 1.03, 1.67) when compared to adequate preparations. The rate of inadequate inpatient bowel preparations is high and associated with a significant increase in hospital LOS and costs. We identified five potential predictors of inadequate inpatient preparation: lower socioeconomic class, opiate/TCA use, afternoon colonoscopies, ASA class ≥3, and pre-preparation nausea/vomiting; these data should guide future initiatives to improve the quality of inpatient bowel preparations.

Assessing Prolongation of the Heart Rate Corrected QT Interval in Users of Tricyclic Antidepressants: Advice to Use Fridericia Rather Than Bazett's Correction.

A prolonged heart rate corrected QT interval (QTc) increases the risk of sudden cardiac death. Some methods of heart rate correction (notably Bazett) overestimate QTc in people with high heart rates. Studies suggest that tricyclic antidepressants (TCAs) can prolong the QTc and increase heart rate. Therefore, we aimed to study whether TCA-induced QTc prolongation is a false-positive observation due to overestimation at high heart rates. For this, we included 12,734 participants from the prospective population-based Rotterdam Study, with a total of 27,068 electrocardiograms (ECGs), of which, 331 during TCA use. Associations between use of TCAs, QTc, and heart rate were studied with linear repeated measurement analyses. QT was corrected for heart rate according to Bazett (QTcBazett), Fridericia (QTcFridericia), or a correction based on regression coefficients obtained from the Rotterdam Study data (QTcStatistical). On ECGs recorded during TCA use, QTcBazett was 6.5 milliseconds (95% confidence interval, 4.0-9.0) longer, and heart rate was 5.8 beats per minute (95% confidence interval, 4.7-6.9) faster than during nonuse. QTcFridericia and QTcStatistical were not statistically significantly longer during TCA use than during nonuse. Furthermore, QTcBazett was similar for ECGs recorded during TCA use and nonuse after statistical adjustment for heart rate. According to our results, TCA use does not seem to be associated with QTc prolongation. Therefore, the current advice of regulatory authorities to restrict the use of these drugs and to do regular checkups of the QTc may need to be revised. Other formulas, like Fridericia's, might be preferred.

Review of antidepressants in the treatment of neuropathic pain

Abstract Introduction Neuropathy is a pathological pain disorder characterized by burning, stabbing, and cramping sensations. There are multiple etiologies for this pain such as diabetes, vascular disorders, and chemotherapy treatment. Neurotransmitters, such as norepinephrine and serotonin, are thought to play a part in the modulation of this pain. The objective of this review is to summarize the current literature to support the efficacy and impact of adverse events of the various classes of antidepressants utilized in the treatment of neuropathic pain. Methods A Medline/Pubmed search was conducted to identify randomized clinical trials within the last 12 years examining the efficacy and safety of antidepressants for the treatment of neuropathy. Systematic reviews and meta-analyses were also included. Results Antidepressants are commonly used in the treatment of neuropathy, with meta-analyses supporting the use of tricyclic antidepressants and selective norepinephrine serotonin reuptake inhibitors. Trials indicate that venlafaxine, duloxetine, and tricyclic antidepressants (TCAs) have comparable efficacy, but TCAs have a higher incidence of adverse effects. Other antidepressants, such as citalopram, paroxetine, and bupropion have limited evidence supporting their use in neuropathy. Discussion Based on the evidence reviewed, venlafaxine and duloxetine should be used as first-line agents. TCAs should be used as second-line agents, due to higher incidence of adverse effects. Other treatment options include citalopram, paroxetine, and bupropion, but data supporting their efficacy is limited.

Bupropion use and risk of open-angle glaucoma among enrollees in a large U.S. managed care network.

ObjectiveTumor Necrosis Factor (TNF) mediates retinal ganglion cell death in glaucoma. Anti-TNF drugs are neuroprotective in an animal model of glaucoma. It is unclear whether medications with anti-TNF properties such as bupropion have an impact on the risk of developing open-angle glaucoma (OAG) in humans. The purpose of this study is to determine whether bupropion use alters the risk of developing OAG.MethodsClaims data for beneficiaries age ≥35 years with no pre-existing OAG enrolled in a large nationwide U.S. managed care network continuously for ≥4 years between 2001-2011 was analyzed to identify patients who had been newly-diagnosed with OAG. The amount of bupropion use as captured from outpatient pharmacy claims over a four-year period was also quantified for each beneficiary. Multivariable Cox regression modeling assessed the impact of bupropion and other antidepressant medications on the risk of developing OAG with adjustment for sociodemographic characteristics of the enrollees along with medical and ocular comorbidities.ResultsOf 638,481 eligible enrollees, 15,292 (2.4%) developed OAG. After adjustment for confounding factors including use of other antidepressant medication classes, each additional month of bupropion use was associated with a 0.6% reduced risk of OAG (HR = 0.994, (95% CI: 0.989-0.998), p = 0.007). Compared to nonusers, those with 24-48 months of bupropion use had a 21% reduced hazard (HR=0.79, (CI: 0.65-0.94), p = 0.0099) of OAG. This association did not differ among persons taking bupropion for depression or for other reasons (p-interaction = 0.82). There was no significant association between use of tricyclic antidepressants (HR = 1.000, (CI: 0.997-1.004), p = 0.95) or selective serotonin reuptake inhibitors (HR = 0.999, (CI: 0.997-1.001), p = 0.39) and development of OAG.ConclusionThese findings suggest bupropion use may be beneficial in reducing the risk of OAG. If prospective studies confirm the findings of this analysis, this may identify a novel therapeutic target for OAG.

Neuropathic pain: New analysis sheds light on optimal drug therapy

Finer points Finnerup and colleagues conducted a systematic review and meta-analysis of 229 reports or trials (both published and unpublished) that assessed the use of systemic and topical therapies for the treatment of neuropathic pain. They applied their results to update current practice recommendations released by the Special Interest Group on Neuropathic Pain (NeuPSIG). The investigators noted that most trial outcomes were modest and publication bias may account for a 10% overstatement of treatment effects. On the basis of GRADE recommendations, the analysis showed that there is strong evidence to support the use of tricyclic antidepressants, serotonin–noradrenaline reuptake inhibitors (particularly duloxetine), pregabalin, and gabapentin as rst-line agents for patients with neuropathic pain. Capsaicin 8% patches, lidocaine patches, tramadol, subcutaneous botulinum toxin A, and strong opioids all had weak GRADE recommendations for use based on poorer evidence, high costs, or safety concerns. Both high-concentration capsaicin and lidocaine patches were recommended as second-line agents for peripheral neuropathic pain, and botulinum toxin A as a third-line agent when used by a specialist to manage this condition.

Effects of chronic doxepin and amitriptyline administration in naïve mice and in neuropathic pain mice model

Neuropathic pain is a severe clinical problem, often appearing as a co-symptom of many diseases or manifesting as a result of damage to the nervous system. Many drugs and agents are currently used for the treatment of neuropathic pain, such as tricyclic antidepressants (TCAs). The aims of this paper were to test the effects of two classic TCAs, doxepin and amitriptyline, in naïve animals and in a model of neuropathic pain and to determine the role of cytokine activation in the effects of these drugs. All experiments were carried out with Albino-Swiss mice using behavioral tests (von Frey test and the cold plate test) and biochemical analyses (qRT-PCR and Western blot). In the mice subjected to chronic constriction injury (CCI), doxepin and amitriptyline attenuated the symptoms of neuropathic pain and diminished the CCI-induced increase in the levels of spinal interleukin (IL)-6 and -1β mRNA, but not the protein levels of these cytokines, measured on day 12. Unexpectedly, chronic administration of doxepin or amitriptyline for 12days produced allodynia and hyperalgesia in naïve mice. The treatment with these drugs did not influence the spinal levels of IL-1β and IL-6 mRNA, however, the protein levels of these pronociceptive factors were increased. The administration of ondansetron (5-HT3 receptor antagonist) significantly weakened the allodynia and hyperalgesia induced by both antidepressants in naïve mice; in contrast, yohimbine (α2-adrenergic receptors antagonist) did not influence these effects. Allodynia and hyperalgesia induced in naïve animals by amitriptyline and doxepin may be associated with an increase in the levels of pronociceptive cytokines resulting from 5-HT3-induced hypersensitivity. Our results provide new and important information about the possible side effects of antidepressants. Further investigation of these mechanisms may help to guide decisions about the use of classic TCAs for therapy.

The Association between Antidepressant Medications and Coronary Heart Disease in Brazil: A Cross-Sectional Analysis on the Brazilian Longitudinal Study of Adult Health (ELSA-Brazil).

Background: Recent studies have highlighted associations between use of antidepressant medications and coronary heart disease (CHD). Tricyclic antidepressants (TCA) are not recommended in patients with CHD as they may increase morbidity and mortality. However, this class of antidepressants is freely prescribed in public health pharmacies, while access to other classes of antidepressants is restricted in Brazil. Here, we examine the associations between antidepressant use and prevalent CHD in a large cohort from Brazil.Methods: Participants included 14,994 civil servants aged 35–74 years from the baseline assessment of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). CHD (n = 710) included stable angina, myocardial infarction, and coronary revascularization. Univariate (unadjusted) and multivariate (adjusted) logistic regression analyses were conducted to estimate odds ratios and confidence intervals.Results: After full adjustment for covariates, TCA use (n = 156) was associated with a twofold increase in prevalent CHD, relative to non-use (n = 14,076). Additional sensitivity analysis revealed a threefold association for myocardial infarction (OR: 2.96, 95% CI: 1.41–6.21) and coronary revascularization (OR: 2.92, 95% CI: 1.28–6.66). There were no significant associations between antidepressant use and stable angina pectoris.Conclusion: Findings highlight a strong association between TCA use and prevalent CHD. While the cross-sectional design is an important limitation of the present study, findings have important implications for the treatment of cardiac patients in Brazil.

Predicting inadequate bowel preparation for colonoscopy in participants receiving split-dose bowel preparation: development and validation of a prediction score

Adequate bowel preparation is important for optimal colonoscopy. It is important to identify patients at risk for inadequate bowel preparation because this allows taking precautions in this specific group. To develop a prediction score to identify patients at risk for inadequate bowel preparation who may benefit from an intensified bowel cleansing regimen. Patient and colonoscopy data were prospectively collected, whereas clinical data were retrospectively collected for a total of 1996 colonoscopies in participants who received split-dose bowel preparation. Multivariate logistic regression analyses were conducted in a random two-thirds of the cohort to develop a prediction model.Validation and evaluation of the discriminative power of the prediction model were performed within the remaining one-third of the cohort. Four centers, including one academic and three medium-to-large size nonacademic centers. Consecutive colonoscopies in November and December2012. Mean age was 57.3 ± 15.9 years, 45.8% were male and indications for colonoscopy were screening and/or surveillance (27%), abdominal symptoms and/or blood loss and/or anemia (60%), inflammatory bowel disease (9%), and others (4%). Colonoscopy. Inadequate bowel preparation defined as Boston Bowel Preparation Scale score<6. A total of 1331 colonoscopies were included in the development cohort, of which 172 (12.9%) had aninadequate bowel preparation. Independent factors included in the prediction model were American Society of Anesthesiologists Physical Status Classification System score≥3, use of tricyclic antidepressants, use of opioids, diabetes, chronic constipation, history of abdominal and/or pelvic surgery, history of inadequate bowel preparation, and current hospitalization. The discriminative ability of the scale was good, with an area under the curve of 0.77 in the validation cohort. Study design partially retrospective, no data on patient compliance. We developed a validated, easy-to-use prediction scale that can be used to identify subjects with an increased risk of inadequate bowel preparation with good accuracy.

Treatment of complex regional pain syndrome.

Complex Regional Pain Syndrome (CRPS) is a multifactorial and disabling disorder with complex etiology and pathogenesis. Goals of therapy in CRPS should be pain relief, functional restoration, and psychological stabilization, but early interventions are needed in order to achieve these objectives. Several drugs have been used to reduce pain and to improve functional status in CRPS, despite the lack of scientific evidence supporting their use in this scenario. They include anti-inflammatory drugs, analgesics, anesthetics, anticonvulsants, antidepressants, oral muscle relaxants, corticosteroids, calcitonin, bisphosphonates, calcium channel blockers and topical agents. NSAIDs showed no value in treating CRPS. Glucocorticoids are the only anti-inflammatory drugs for which there is direct clinical trial evidence in early stage of CRPS. Opioids are a reasonable second or third-line treatment option, but tolerance and long term toxicity are unresolved issues. The use of anticonvulsants and tricyclic antidepressants has not been well investigated for pain management in CRPS. During the last years, bisphosphonates have been the mostly studied pharmacologic agents in CRPS treatment and there are good evidence to support their use in this condition. Recently, the efficacy of intravenous (IV) administration of neridronate has been reported in a randomized controlled trial. Significant improvements in VAS score and other indices of pain and quality of life in patients who received four 100 mg IV doses of neridronate versus placebo were reported. These findings were confirmed in the open-extension phase of the study, when patients formerly enrolled in the placebo group received neridronate at the same dosage, and these results were maintained at 1 year follow-up. The current literature concerning sympathetic blocks and sympathectomy techniques lacks evidence of efficacy. Low evidence was recorded for a free radical scavenger, dimethylsulphoxide (DMSO) cream (50%). The same level of efficacy was noted for vitamin C (500 mg per day for 50 days) in prevention of CRPS in patients affected by wrist fracture. In conclusion, the best available therapeutic approach to CRPS is multimodal and is based on the use of several classes of drugs, associated to early physiotherapy. Neridronate at appropriate doses is associated with clinically relevant and persistent benefits in CRPS patients.

Antidepressant use and the risk of suicide: A population-based cohort study

BackgroundThe existing literature provides contradictory evidence on antidepressant use and risk of suicide. Some studies have shown that the use of Selective Serotonin Reuptake Inhibitors (SSRIs) is associated with an increased risk of suicide, especially during the first months of treatment, whereas other studies did not confirm this association. For this reason, our objective was to investigate the association between antidepressant use and risk of suicide in incident antidepressant users in relation to time since starting therapy. MethodsWe conducted a population-based cohort study within the Dutch Integrated Primary Care Information (IPCI) database, in incident users of antidepressant therapy between 1994 and 2012 (n=27,712). Cox proportional hazard models were used to study the association between current use of SSRIs, tricyclic antidepressants (TCA) and other antidepressants and risk of suicide or attempted suicide. ResultsDuring follow-up, a total of 280 incident antidepressant users attempted or committed suicide. Current use of SSRIs (hazard ratio (HR): 0.78, 95% CI: 0.57–1.07), TCAs (HR: 0.82, 95% CI: 0.48–1.42) or other antidepressants (HR: 0.75, 95% CI: 0.47–1.18) was not statistically significantly associated with suicide compared to past use of any of the antidepressants. LimitationsAlthough a large healthcare database was used, the number of reported cases of suicide (attempt) was low. ConclusionsThis study did not indicate an increase in risk of suicide after starting treatment with SSRIs, TCAs or other antidepressants compared with past antidepressant use.

Trends in the use of antidepressants among older adults: Bambuí Project.

OBJECTIVETo analyze the trends and factors associated with the antidepressant use among older adults.METHODSThis population-based study evaluated older adults in 1997 (n = 351, baseline) and the survivors at the 15th follow-up year (n = 462, in 2012) among the aging cohort of Bambuí. The prevalence of antidepressant use was estimated, and the most commonly used antidepressants each year were identified. Prevalence ratios with 95% confidence intervals were estimated using Poisson regression with robust variance to investigate differences in the prevalence of use between 1997 and 2012.RESULTSThe overall consumption of antidepressants (PR = 2.87, 95%CI 1.94;4.25) and of selective serotonin reuptake inhibitors (PR = 7.50, 95%CI 3.74;15.02) was significantly higher in 2012. However, no significant difference was observed in the use of tricyclic antidepressants between the two cohorts (PR = 0.89, 95%CI 0.49;1.62). In the 2012 cohort, antidepressant use was associated with females, increased age, increased income (≥ 4 minimum wages), self-assessment of health as reasonable, and attending ≥ 5 medical consultations in the last 12 months.CONCLUSIONSThe increased consumption of antidepressants in the period due to increased use of selective serotonin reuptake inhibitors was consistent with results observed in international studies of different population groups and contexts. The positive correlation observed between antidepressant use and family income may be a warning of possible inequalities in access to mental health services.

Use of antidepressants and association with elective termination of pregnancy: population based case-control study.

To assess whether the use of selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, mirtazapine, venlafaxine or other antidepressants is associated with late elective termination of pregnancy. Case-control study using data from national registers. Denmark, Finland, and Norway during the period 1996-2007. A total of 14,902 women were included as cases and 148,929 women were included as controls. Cases were women with elective termination of pregnancy at 12-23 weeks of gestation. Controls continued their pregnancy and were matched with cases on key factors. Association between antidepressant use during pregnancy and elective termination of pregnancy at 12-23 weeks of gestation for fetal anomalies, or for maternal ill health or socio-economic disadvantage. At least one prescription of antidepressants was filled by 3.7% of the cases and 2.2% of the controls. Use of any type of antidepressant was associated with elective termination of pregnancy for maternal ill health or socio-economic disadvantage (odds ratio, OR 2.3; 95% confidence interval, 95% CI 2.0-2.5). Elective termination of pregnancy for fetal anomalies was associated with the use of mirtazapine (OR 2.2, 95% CI 1.1-4.5). There was no association between the use of any of the other antidepressants and elective termination of pregnancy for fetal anomalies. The use of any type of antidepressants was associated with elective termination of pregnancy at 12-23 weeks for maternal ill health or socio-economic disadvantage, but not with terminations for fetal anomalies. Further studies need to confirm the findings concerning mirtazapine and termination of pregnancy for fetal anomalies.