Assessing clinical and functional outcomes in the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial.
(25/225)
Schizophrenia is a symptomatically heterogeneous disorder characterized by the presence of positive and negative symptoms, and variable impairment in community functioning. Given the diversity of symptom presentations and functioning associated with schizophrenia, one of the key challenges facing the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial was the selection of efficient assessment measures appropriate to a community-based effectiveness trial. This article describes the rationale for the measurement approach adopted for the trial, provides a brief overview of the selected measures, and describes the process of training assessment raters for a large and geographically dispersed study group. (+info)
This article describes the development of the protocol for the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Alzheimer's disease trial, which was developed in collaboration with the National Institute of Mental Health to assess the effectiveness of atypical antipsychotics for psychosis and/or agitation occurring in outpatients with Alzheimer's disease. The article provides a detailed description of the methodology used in the trial as well as the clinical outcomes and effectiveness measures incorporated into it, discussing the most salient issues encountered in developing the design of the trial, as well as the unique features of the trial. (+info)
The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity.
(27/225)
BACKGROUND: There are difficulties with the diagnosis of serotonin toxicity, particularly with the use of Sternbach's criteria. AIM: To improve the criteria for diagnosing clinically significant serotonin toxicity. DESIGN: Retrospective analysis of prospectively collected data METHODS: We studied all patients admitted to the Hunter Area Toxicology Service (HATS) following an overdose of a serotonergic drug from January 1987 to November 2002 (n = 2222). Main outcomes were: diagnosis of serotonin toxicity by a clinical toxicologist, fulfillment of Sternbach's criteria and treatment with a serotonin receptor (5-HT(2A)) antagonist. A learning dataset of 473 selective serotonin reuptake inhibitor (SSRI)-alone overdoses was used to determine individual clinical features predictive of serotonin toxicity by univariate analysis. Decision rules using CART analysis were developed, and tested on the dataset of all serotonergic overdose admissions. RESULTS: Numerous clinical features were associated with serotonin toxicity, but only clonus (inducible, spontaneous or ocular), agitation, diaphoresis, tremor and hyperreflexia were needed for accurate prediction of serotonin toxicity as diagnosed by a clinical toxicologist. Although the learning dataset did not include patients with life-threatening serotonin toxicity, hypertonicity and maximum temperature > 38 degrees C were universal in such patients; these features were therefore added. Using these seven clinical features, decision rules (the Hunter Serotonin Toxicity Criteria) were developed. These new criteria were simpler, more sensitive (84% vs. 75%) and more specific (97% vs. 96%) than Sternbach's criteria. DISCUSSION: These redefined criteria for serotonin toxicity should be more sensitive to serotonin toxicity and less likely to yield false positives. (+info)
Rapid tranquillisation for agitated patients in emergency psychiatric rooms: a randomised trial of midazolam versus haloperidol plus promethazine.
(28/225)
OBJECTIVE: To compare two widely used drug treatments for people with aggression or agitation due to mental illness. DESIGN: Pragmatic, randomised clinical trial. SETTING: Three psychiatric emergency rooms in Rio de Janeiro, Brazil. SUBJECTS: 301 aggressive or agitated people. INTERVENTIONS: Open treatment with intramuscular midazolam or intramuscular haloperidol plus promethazine. MAIN OUTCOME MEASURES: Patients tranquil or sedated at 20 minutes. SECONDARY OUTCOMES: patients tranquil or asleep by 40, 60, and 120 minutes; restrained or given extra drugs within 2 hours; severe adverse events; another episode of agitation or aggression; needing extra visits from doctor during first 24 hours; overall antipsychotic load in first 24 hours; and not discharged by two weeks. RESULTS: 151 patients were randomised to midazolam, and 150 to haloperidol-promethazine mix. Follow up for the primary outcome was available for 298 (99%): 134/151 (89%) of patients given midazolam were tranquil or asleep after 20 minutes compared with 101/150 (67%) of those given haloperidol plus promethazine (relative risk 1.32 (95% confidence interval 1.16 to 1.49)). By 40 minutes, midazolam still had a statistically and clinically significant 13% relative advantage (1.13 (1.01 to 1.26)). After 1 hour, about 90% of both groups were tranquil or asleep. One important adverse event occurred in each group: a patient given midazolam had transient respiratory depression, and one given haloperidol-promethazine had a grande mal seizure. CONCLUSIONS: Both treatments were effective. Midazolam was more rapidly sedating than haloperidol-promethazine, reducing the time people are exposed to aggression. Adverse effects and resources to deal with them should be considered in the choice of the treatment. (+info)
The causes of underdiagnosing akathisia.
(29/225)
This article reviews what causes clinicians to overlook or underdiagnose akathisia. The causes are considered to be related to both the patient's symptoms and the clinician's attitude toward akathisia. The patient factors include mild severity of akathisia, lack of apparent motor restlessness, no voluntary expression of inner restlessness, no clear communication of inner restlessness, restlessness in body parts other than the legs, atypical expressions of inner restlessness, other prominent psychic symptoms, and absence of other extrapyramidal signs. The clinician factors include emphasis on objective restlessness, failure to consider akathisia during antipsychotic therapy, failure to fully implement antiakathisia treatments in ambiguous cases, and strict adherence to research diagnostic criteria. Akathisia is likely to be overlooked or underdiagnosed when both patient and clinician factors are present. Currently, there may be two major problems with underdiagnosis: (1) symptoms that fulfill the diagnostic criteria for akathisia are overlooked, and (2) conditions that do not fulfill the diagnostic criteria but can still benefit from antiakathisia measures are underdiagnosed. (+info)
Dementia associated mental and behavioural disturbances in elderly people in the community: findings from the first Nakayama study.
(30/225)
OBJECTIVE: To determine the prevalence of mental and behavioural disturbances associated with dementia in elderly people living in the Japanese community of Nakayama. METHODS: A door to door three phase population survey was carried out on all persons aged 65 years and older living at home. The study included a psychiatric interview, neurological and neuropsychological examination, and cranial computed tomography. Participants with dementia were rated on the neuropsychiatric inventory. RESULTS: Of 1438 inhabitants, 1162 (81.0%) completed the protocol. The prevalence of dementia was 4.8%. Of the 60 participants with dementia (Alzheimer's disease 35%, vascular dementia 47%, and dementia from other causes 17%), 53 (88.3%) had shown one or more mental and behavioural disturbances. Apathy/indifference (56.7%), followed by agitation/aggression (35%), aberrant motor behaviour (31.7%), and irritability (31.7%) were the common symptoms. More productive (positive) symptoms such as delusions and aberrant motor behaviour were found in the Alzheimer group than in the vascular dementia group. CONCLUSIONS: A wide range of dementia associated mental and behavioural disturbances developed in the majority of community dwelling individuals with dementia. The findings suggest that a screening programme focusing on identifying these symptoms should be included in the physician's diagnostic tools for dementia. (+info)
Predictors of antisocial personality. Continuities from childhood to adult life.
(31/225)
BACKGROUND: Antisocial behaviour in adult life has its roots in childhood. AIMS: To explore the independent and joint effects of childhood characteristics on the persistence of antisocial behaviour into adult life. METHOD: A clinical sample of twins who were systematically ascertained in childhood was followed up 10-25 years later. A total of 225 twins were interviewed regarding childhood and adult psychiatric disorder, psychosocial functioning, and psychosocial and cognitive risk factors. RESULTS: In univariate analyses, childhood hyperactivity and conduct disorder showed equally strong prediction of antisocial personality disorder (ASPD) and criminality in early and mid-adult life. Lower IQ and reading problems were most prominent in their relationships with childhood and adolescent antisocial behaviour. In multivariate modelling childhood conduct disorder and hyperactivity predicted adult ASPD even when intervening risk factors were accounted for. The number of hyperactive and conduct symptoms also predicted adult outcome. CONCLUSIONS: Childhood disruptive behaviour has powerful long-term effects on adult antisocial outcomes, which continue into middle adulthood. The importance of number of symptoms, the presence of disruptive disorder, and intermediate experiences highlight three areas where interventions might be targeted. (+info)
Offset of pharmacodynamic effects and safety of remifentanil in intensive care unit patients with various degrees of renal impairment.
(32/225)
INTRODUCTION: This open label, multicentre study was conducted to assess the times to offset of the pharmacodynamic effects and the safety of remifentanil in patients with varying degrees of renal impairment requiring intensive care. METHODS: A total of 40 patients, who were aged 18 years or older and had normal/mildly impaired renal function (estimated creatinine clearance >/= 50 ml/min; n = 10) or moderate/severe renal impairment (estimated creatinine clearance <50 ml/min; n = 30), were entered into the study. Remifentanil was infused for up to 72 hours (initial rate 6-9 microgram/kg per hour), with propofol administered if required, to achieve a target Sedation-Agitation Scale score of 2-4, with no or mild pain. RESULTS: There was no evidence of increased offset time with increased duration of exposure to remifentanil in either group. The time to offset of the effects of remifentanil (at 8, 24, 48 and 72 hours during scheduled down-titrations of the infusion) were more variable and were statistically significantly longer in the moderate/severe group than in the normal/mild group at 24 hours and 72 hours. These observed differences were not clinically significant (the difference in mean offset at 72 hours was only 16.5 min). Propofol consumption was lower with the remifentanil based technique than with hypnotic based sedative techniques. There were no statistically significant differences between the renal function groups in the incidence of adverse events, and no deaths were attributable to remifentanil use. CONCLUSION: Remifentanil was well tolerated, and the offset of pharmacodynamic effects was not prolonged either as a result of renal dysfunction or prolonged infusion up to 72 hours. (+info)