Cigarette and e-cigarette use trajectories and prospective prescription psychotherapeutic drug misuse among adolescents and young adults.

OBJECTIVE: This study aimed to determine the potential longitudinal impact of different cigarette and e-cigarette use trajectories among people aged 10-24 on prescription drug misuse of psychotherapeutic drugs. METHODS: Data came from waves 1-5 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2019; n = 14,454). Group-based trajectory modeling identified groups of adolescents and young adults based on cigarette and e-cigarette use across the five waves. Weighted logistic regression models were fit to examine the association of group membership with two outcomes at all waves: 1) misuse of opioids, sedatives, and/or tranquilizers, and 2) misuse of Ritalin and/or Adderall, adjusting for background characteristics. RESULTS: Five trajectory groups emerged: (1) non-use (77.7 %); (2) early-onset cigarette use with reducing use (4.6 %); (3) ever-increasing e-cigarette use (6.1 %); (4) stable dual use of cigarettes and e-cigarettes (3.2 %); and (5) accelerating dual use of cigarettes and e-cigarettes (8.4 %). In comparison to the non-use group, all other groups had significantly higher odds of misuse of opioids, tranquilizers, and/or sedatives and all but the early-onset cigarette use with reducing use group had significantly higher odds of misuse of Ritalin and/or Adderall by the end of wave 5. DISCUSSION: Patterns of cigarette and e-cigarette use in adolescent and young adult populations may serve as important indicators for concurrent and prospective prescription psychotherapeutic drug misuse. Findings highlight the need for cigarette and e-cigarette use prevention, harm reduction, and/or cessation efforts among adolescents and young adults.

Prescription Psychotherapeutic Drug Use and Nicotine Use among Young People in the United States.

Background: While prescription psychotherapeutic drug use (PPDU) and nicotine use pose substantial problems in isolation, they pose an increased risk in combination. This study aimed to estimate the prevalence of PPDU for young people, stratified by nicotine use status. A trend analysis was used to examine changes in PPDU and nicotine use over time. Methods: We used a cross-sectional population-based sample of young people aged 16-25 years (n = 10,454) from the National Health and Nutrition Examination Survey (NHANES, 2003-2018). For each data cycle, the prevalence of self-reported PPDU and nicotine including pain relievers, sedatives, stimulants, and tranquilizers was estimated. Using Joinpoint regression, we tested for significant changes in trends using a log-linear model and permutation test approach and produced the average data cycle percentage change (ADCPC). Results: From 2003 to 2018, 6.7% of young people had PPDU and 27.3% used nicotine. The prevalence of cigarette smoking decreased while other nicotine product use increased (p's < 0.001). Those who used nicotine were more likely to have PPDU (8.2%; 95% CI = 6.5%, 9.8%) vs. non-nicotine use (6.1%; 95% CI = 5.1%, 7.0%; p = 0.01). Results indicated a decreasing trend for nicotine use (ADCPC = -3.8, 95% CI = -7.2, -0.3; p = 0.04), but not for PPDU (ADCPC = 1.3; 95% CI = -4.7, 7.8; p = 0.61). On further examination, opioid use decreased, sedative use remained stable, and stimulant and tranquilizer use increased over time. Conclusions: From 2003 to 2018, young people who used nicotine had a higher prevalence of PPDU than those who did not. Clinicians should communicate the association between nicotine use and prescription drugs when prescribing or managing young patients' medications.

Feline hyperaesthesia syndrome with self-trauma to the tail: retrospective study of seven cases and proposal for an integrated multidisciplinary diagnostic approach.

CASE SERIES SUMMARY: This was a retrospective study on the clinical features and response to treatment in seven cats with feline hyperaesthesia syndrome (FHS) and tail mutilation. FHS is a poorly understood disorder characterised by skin rippling over the dorsal lumbar area, episodes of jumping and running, excessive vocalisation, and tail chasing and self-trauma. The majority of the cats were young, with a median age of 1 year at the onset of clinical signs, male (n = 6) and with access to the outdoors (n = 5). Multiple daily episodes of tail chasing and self-trauma were reported in five cats, with tail mutilation in four cats. Vocalisation during the episodes (n = 5) and rippling of lumbar skin (n = 5) were also reported. Haematology, serum biochemistry, Toxoplasma gondii and feline immunodeficiency virus/feline leukaemia virus serology, MRI scans of brain, spinal cord and cauda equina, cerebrospinal fluid analysis and electrodiagnostic tests did not reveal any clinically significant abnormalities. A definitive final diagnosis was not reached in any of the cats, but hypersensitivity dermatitis was suspected in two cases. A variety of medications was used alone or in combination, including gabapentin (n = 6), meloxicam (n = 4), antibiotics (n = 4), phenobarbital (n = 2), prednisolone (n = 2) and topiramate (n = 2); ciclosporin, clomipramine, fluoxetine, amitriptyline and tramadol were used in one cat each. Clinical improvement was achieved in six cases; in five cats complete remission of clinical signs was achieved with gabapentin alone (n = 2), a combination of gabapentin/ciclosporin/amitriptyline (n = 1), gabapentin/prednisolone/phenobarbital (n = 1) or gabapentin/topiramate/meloxicam (n = 1). RELEVANCE AND NOVEL INFORMATION: This is the first retrospective study on a series of cats with FHS. The diagnostic work-up did not reveal any significant abnormalities of the central or peripheral nervous system; dermatological and behavioural problems could not be ruled out. We propose an integrated multidisciplinary diagnostic pathway to be used for the management of clinical cases and for future prospective studies.

Trends of Polypharmacy and Prescription Patterns of Antidepressants in Asia.

PURPOSE: Little is known regarding the trend of polypharmacy in Asia. We used data from 5 Asian countries to examine the patterns of antidepressant (AD) prescription and trends of psychotropic polypharmacy over time. METHODS: We used the cross-sectional, pharmacoepidemiological data from 2004 and 2013 REAP-AD (Research on Asian Psychotropic Prescription Patterns for Antidepressants) to examine the patterns of AD prescriptions in clinical settings in China, Japan, Korea, Singapore, and Taiwan. We compared the trend in polypharmacy (ie, concomitant use of ≥2 classes of psychotropic) among individuals receiving AD prescriptions in 2004 and 2013 using multivariable logistic regression models in different diagnostic categories. RESULTS: The proportion of patients with psychotropic polypharmacy decreased from 2004 to 2013 in all 3 diagnostic categories, including mood disorders (adjusted odds ratio [aOR], 0.44 [0.35-0.56]; P < 0.001), anxiety disorders (aOR, 0.58 [0.36-0.94]; P = 0.028), and psychotic disorders (aOR, 0.18 [0.05-0.60]; P = 0.006). Among individuals with AD prescriptions, concomitant use of anxiolytics (including sedative-hypnotics) decreased in patients with mood disorders (aOR, 0.34 [0.27-0.42]; P < 0.001) and anxiety disorders (aOR, 0.43 [0.27-0.67]; P < 0.001). In contrast, concomitant use of antipsychotics in patients with mood disorders increased (aOR, 1.43 [1.15-1.77]; P = 0.001), and concomitant use of mood stabilizers in patients with psychotic disorders also increased (aOR, 3.49 [1.50-8.14]; P = 0.004). CONCLUSIONS: This is the first study examining trends in psychotropic polypharmacy in East Asia. We found a generally decreasing trend of psychotropic polypharmacy in contrast to the increasing trend reported from Western countries. These findings could offer significant implications for health system reform or policy making.

Leisure time physical activity and incident use of prescription tranquilizers: A longitudinal population-based study.

OBJECTIVE: Physical inactivity is a major public health problem associated with an increased risk of several psychiatric and physical conditions. This study investigated the association between leisure time physical activity (PA) and incident use of prescription tranquilizers in a regionally representative and prospective cohort. METHODS: A total of 4043 men and women (mean age: 61.3 years; 57% women) from the Tromsø Study were followed for six years. Leisure time PA was captured at baseline. Psychiatric morbidity was measured by use of prescription tranquilizers, captured at both baseline and follow-up. Leisure time PA at baseline was used as a predictor of subsequent (incident) use of prescription tranquilizers. We used multinomial regression models and Poisson regression models to estimate relative risk-ratios (RRRs), and relative risks (RRs), respectively, and their corresponding 95% confidence intervals (CIs). RESULTS: In the fully-adjusted model, accounting for socio-demographic factors, parental history of psychopathology, years of education, smoking, respondent's psychopathology at baseline, and occupational PA, a lower leisure time PA conferred a 41% increased risk of incident use of prescription tranquilizers at follow-up (RR = 1.41, 95% CI: 1.09, 1.83; p = 0.010). CONCLUSIONS: These findings suggest that physical inactivity increases the risk of psychiatric morbidity (albeit, measured via use of prescription tranquilizers). Future regionally representative and longitudinal research is required to confirm/refute our findings and explore underlying mechanisms.

Prescription drug use and misuse in a cohort of people who inject drugs (PWID) in Baltimore.

BACKGROUND: Prescription drug misuse and its consequences (e.g., overdose) are a major public health concern. While national focus has been on opioids, misuse of sedatives/tranquilizers also occurs. Here we describe the use, correlates, and sources of prescription drugs in a community-based cohort of people who inject drugs (PWID). METHODS: We included participants of the AIDS Linked to the IntraVenous Experience (ALIVE) study in follow-up in 2014. We defined prescription drug use as use of opioids or sedatives/tranquilizers considering both medical "prescribed by a doctor" and non-medical sources "obtained from the street/friend/relative." Correlates were evaluated separately for opioids and sedatives/tranquilizers using logistic regression and included socioeconomic factors, health conditions, substance use, and health care access. RESULTS: 823 predominantly African-American (90.6%) and male (66.3%) ALIVE participants with a median age of 55 were included. Prevalence of prescription opioid and sedative/tranquilizer use was 25.3% and 16.3% respectively. While the majority (70%) obtained prescription drugs exclusively through medical sources, the 30% who reported any non-medical source were also more likely to use other substances by injection and non-injection routes. PWID reporting prescription drug use (from medical and non-medical sources) were significantly more likely to report other substance use, mental health disorder, and recent contact with health care providers or detoxification facilities. CONCLUSIONS: Prescription drug use was highly prevalent among PWID. While it is difficult to distinguish medically indicated from non-medical use, high levels of prescription drug use in conjunction with other drugs and alcohol heightens the risk for drug overdose and other adverse consequences.

The minimal clinically important difference of the Richmond Agitation-Sedation Scale in patients with cancer with agitated delirium.

BACKGROUND: The Richmond Agitation-Sedation Scale (RASS) is commonly used to assess psychomotor activity; however, to the authors' knowledge, its minimal clinically important difference (MCID) has not been determined to date. The objective of the current study was to identify the MCID for RASS using 2 anchor-based approaches. METHODS: The current study was a secondary analysis of a randomized controlled trial to compare the effect of lorazepam versus placebo as an adjuvant to haloperidol for persistent agitation in patients with delirium. The primary outcome was change in RASS (10-point numeric rating scale ranging from -5 [unarousable] to +4 [combative]) from baseline to 8 hours after treatment administration. The sensitivity-specificity and within-patient change methods were used to identify the MCID, with the anchor being patient comfort after the study intervention as perceived by caregivers and nurses. RESULTS: A total of 90 patients were randomized and 58 (64%) received the study medication for restlessness/agitation (mean baseline RASS, 1.6). A total of 23 caregivers (61%) and 23 nurses (55%) perceived that the patient was more comfortable after treatment. Using the sensitivity-specificity method, the optimal RASS reduction was ≥4 points according to both caregivers (sensitivity of 61% and specificity of 80%; area under the curve, 0.71) and nurses (sensitivity of 73% and specificity of 84%; area under the curve, 0.78). The RASS cutoff value based on the within-patient change method was similar (-4.2 for caregivers and -4.0 for nurses). CONCLUSIONS: For patients with persistent restlessness/agitation, a reduction of ≥4 points in RASS was considered to be the MCID for both nurses and caregivers. These preliminary findings may have implications for sample size calculation and the interpretation of treatment effect in future delirium trials. Cancer 2018;124:2246-52. © 2018 American Cancer Society.

Medical use, nonmedical use of prescription medication and risk behaviour among Croatian adolescents.

BACKGROUND: At the drug scene some major shifts were observed, more and more reports highlighted the abuse of prescription medication. Despite the importance of controlled medication in treatment child and adolescent disorders, this increase may be a factor which influence misuse and nonmedical use of prescribed drugs among adolescents. SUBJECT AND METHODS: Croatian data from ESPAD survey in 2003, 2007 and 2011 were used, and variables selected from the international ESPAD questionnaire. Dependent variable was taking tranquilizers or sedatives prescribed by doctor in the past 12 months. Independent variables were nonmedical use of tranquilizers/sedatives, use of other psychoactive substances, school performance, truancy, delinquent behaviour, satisfaction with relationships with parents, friends, health, self-perception, financial situation and symptoms of depression. The respondents were 8849 students (4393 boys and 4456 girls) in three consecutive ESPAD surveys (2003, 2007 and 2011). RESULTS: In multivariate analysis for all three survey years the strongest predictor for prescription medication use was use of sedatives/tranquilizers without prescription (OR 6.14; CI 4.08-9.23; OR 8.16; CI4.65-14.32; OR 9.77; CI5.92-15.13). Frequent drinking and excessive drinking or drunkenness also predicted prescription medication use, (OR 1.85; CI1.10-3.10; OR 2.01: CI 1.20-3.39). Among other problem behaviours lower school performance (OR 2.92; CI 1.41-6.05; OR 2.56; CI 1.12-5.87), missed school days OR 1.59; OR1.01-2.51; OR1.72; CI 1.03-2.87), aggressive behaviour (OR 1.532; CI 1.01-2.28; OR1.65; CI 1.04-2.62), depressive symptoms (OR 2.19; CI 1.24-3.85) and poorer financial situation were connected with prescription medication use. CONCLUSION: Prescription use of tranquilizers/sedatives was predicted by nonmedical tranquilizers/sedatives use, alcohol abuse, symptoms of depression and variables indicating maladjusted behaviour. Although there is sufficient evidence that prescription medication abuse might went unobserved, the further analysis which could better explain its' role and impact is still needed.

Prescribing preferences in rapid tranquillisation: a survey in Belgian psychiatrists and emergency physicians.

BACKGROUND: The pharmacotherapeutic management of agitation is a common clinical challenge. Pharmacotherapy is frequently used, the use of published guidelines is not known. The purpose of this study was twofold; to describe the prescribing patterns of psychiatrists and emergency physicians and to evaluate to which extent guidelines are used. METHODS: A cross-sectional survey in the Dutch-speaking part of Belgium is carried out in 39 psychiatric hospitals, 11 psychiatric wards of a general hospital and 61 emergency departments. All physicians are asked for demographic information, their prescribing preferences, their use of guidelines and the type of monitoring (effectiveness, safety). For the basic demographic data and prescription preferences descriptive statistics are given. For comparing prescribing preferences of the drug between groups Chi square tests (or in case of low numbers Fisher's exact test) were performed. Mc Nemar test for binomial proportions for matched-pair data was performed to see if the prescription preferences of the participants differ between secluded and non-secluded patients. RESULTS: 550 psychiatrist and emergency physicians were invited. The overall response rate was 20% (n = 108). The number 1 preferred medication classes were antipsychotics (59.3%) and benzodiazepines (40.7%). In non-secluded patients, olanzapine (22.2%), lorazepam (21.3%) and clotiapine (19.4%) were most frequently picked as number 1 choice drug. In secluded patients, clotiapine (21.3%), olanzapine (21.3%) and droperidol (14.8%) were the three most frequently chosen number 1 preferred drugs. Between-group comparisons show that emergency physicians prefer benzodiazepines significantly more than psychiatrists do. Zuclopenthixol and olanzapine show a particular profile in both groups of physicians. Polypharmacy is more frequently used in secluded patients. Published guidelines and safety or outcome monitoring are rarely used. CONCLUSIONS: Our results show that prescription practice in Flanders (Belgium) in acute agitation shows a complex relationship with published guidelines. Prescription preferences differ accordingly to medical specialty. These findings should be taken into account in future research.

Nonprescribed use of tranquilizers and use of other drugs among Brazilian students.

OBJECTIVES: To describe patterns of nonprescribed use of tranquilizers by students aged 10 to 18 years and assess the sociodemographic characteristics of these adolescents and their use of other substances. METHODS: A randomized and stratified sample of 47,979 students from state and private schools of the 27 Brazilian state capitals completed a self-report questionnaire. Poisson regression was used to estimate the associations between tranquilizer use and sociodemographic factors, as well as the use of other psychotropic substances. RESULTS: The lifetime prevalence of nonprescribed use of tranquilizers was 3.9%. Use was most common among girls, wealthier adolescents, and those from private schools. An association was found between use of tranquilizers and lifetime use of alcohol (prevalence ratio [PR] = 3.15; 95% confidence intervals [95%CI] 2.58-3.85), tobacco (PR = 2.61; 95%CI 2.31-2.95), illicit drugs (PR = 3.70; 95%CI 3.19-4.29), and other prescription drugs (PR = 7.03; 95%CI 6.18-7.99). As the number of substances adolescents reported having used increased, so did the nonprescribed use of tranquilizers. CONCLUSIONS: Nonprescribed use of tranquilizers by adolescents might indicate the use of other substances, including high-risk combinations such as tranquilizers and alcohol. The risks of this association should be addressed during the early stages of drug prevention programs.

Nonprescribed use of tranquilizers and use of other drugs among Brazilian students

Objectives: To describe patterns of nonprescribed use of tranquilizers by students aged 10 to 18 years and assess the sociodemographic characteristics of these adolescents and their use of other substances. Methods: A randomized and stratified sample of 47,979 students from state and private schools of the 27 Brazilian state capitals completed a self-report questionnaire. Poisson regression was used to estimate the associations between tranquilizer use and sociodemographic factors, as well as the use of other psychotropic substances. Results: The lifetime prevalence of nonprescribed use of tranquilizers was 3.9%. Use was most common among girls, wealthier adolescents, and those from private schools. An association was found between use of tranquilizers and lifetime use of alcohol (prevalence ratio [PR] = 3.15; 95% confidence intervals [95%CI] 2.58-3.85), tobacco (PR = 2.61; 95%CI 2.31-2.95), illicit drugs (PR = 3.70; 95%CI 3.19-4.29), and other prescription drugs (PR = 7.03; 95%CI 6.18-7.99). As the number of substances adolescents reported having used increased, so did the nonprescribed use of tranquilizers. Conclusions: Nonprescribed use of tranquilizers by adolescents might indicate the use of other substances, including high-risk combinations such as tranquilizers and alcohol. The risks of this association should be addressed during the early stages of drug prevention programs. .

[Burning mouth syndrome: pathogenic and therapeutic concepts]. / Zespól pieczenia w jamie ustnej (burning mouth syndrome)--koncepcje patogenetyczne i terapeutyczne.

Burning mouth syndrome (BMS) is a chronic pain condition characterized by pain, burning sensations and dryness within an oral mucosa, without any clinical changes of the latter. It occurs approximately seven times more frequently in women, mostly in perimenopausal age. The psychiatric aspect of BMS is significant: the most frequent co-morbidities are depression and anxiety disorders, and a number of psychotropic drugs play an essential role in its treatment. In the present review, the most important pathogenic and treatment concepts of BMS have been discussed. The BMS may be similar to neuropathic pain and has some related pathogenic elements with fibromyalgia and the restless leg syndrome. In primary BMS, the features of presynaptic dysfunction of dopaminergic neurons and deficiency of endogenous dopamine levels have been demonstrated. Other neurotransmitters such as serotonin, noradrenaline, histamine as well as hormonal and inflammatory factors may also play a role in the pathogenesis of BMS. In the pharmacological treatment of BMS a variety of drugs have been used including benzodiazepines, anticonvulsants, antidepressants and atypical antipsychotic drugs. In the final part of the paper, the possibility of using atypical antipsychotic drug, olanzapine, in the treatment of BMS has been discussed. In the context of the recent studies on this topic, a case of female patient with the BMS lasting more than ten years has been mentioned, in whom the treatment with olanzapine brought about a rapid and significant reduction of symptoms. The probable mechanism of the therapeutic effect of olanzapine in BMS can include its effect on dopaminergic receptors and probably also on histaminergic, noradrenergic and serotonergic ones.

Patterns of coping with partner violence: experiences of refugee women in Jordan.

OBJECTIVE: The relationship between intimate partner violence (IPV) and women's use of negative and positive coping strategies was investigated. DESIGN AND SAMPLE: For this cross-sectional study, a convenience sample of 300 refugee women was recruited from health care centers in three cities in Jordan. Logistic regression adjusted to women's demographic characteristics was used. RESULTS: The study's results revealed that, compared to non victims, victimized women showed a lower tendency to receive psychological support from the family (adjusted OR = 0.53, 95% CI = 0.29-0.96), to smoke (adjusted OR = 0.28, 95% CI = 0.09-0.82), to use tranquilizers (adjusted OR = 0.014, 95% CI = 0.00-0.86), to think of suicide (adjusted OR = 0.04, 95% CI = 0.009-0.15), and to attempt suicidal actions (adjusted OR = 0.02, 95% CI = 0.002-0.19). CONCLUSIONS: The study indicated that women's lack of use of negative coping strategies (smoking, use of tranquilizers, suicidal thoughts, and suicidal actions) was promising. However, the lack of use of positive coping strategies (disclosure of abuse, psychological support from friends, and help from family/friends) was somewhat concerning. The role of health care professionals may be helpful in this context. Counseling and support to IPV victims via effective listening, nonjudgmental discussions, and provision of information can be offered by health professionals as part of the treatment in health care centers.

Pharmacotherapy regimens among patients with posttraumatic stress disorder and mild traumatic brain injury.

OBJECTIVE: The purpose of this study was to determine if veterans with posttraumatic stress disorder (PTSD) and mild traumatic brain injury (TBI) are treated differently pharmacologically than patients with PTSD alone. METHODS: A retrospective evaluation of PTSD pharmacotherapy of Operation Enduring Freedom/Operation Iraqi Freedom veterans with PTSD (N=707) was conducted between April 1, 2007, and March 31, 2009. A total of 45 veterans had suffered a mild TBI. RESULTS: Compared with the patients with PTSD alone, the patients with PTSD and TBI were more likely to be prescribed an antidepressant (p<.001), a sedative-hypnotic (p<.001), or an antipsychotic (p=.024). The patients with TBI were also significantly more likely to receive psychotropic polypharmacy (p=.001) and to receive higher doses of psychiatric medications (p=.03). CONCLUSIONS: The differences in drug therapy found in this study may indicate that patients with TBI and PTSD respond differently to treatment than patients with PTSD alone.

Effect of "rose essential oil" inhalation on stress-induced skin-barrier disruption in rats and humans.

In stressed animals, several brain regions (e.g., hypothalamic paraventricular nucleus [PVN]) exhibit neuronal activation, which increases plasma adrenocorticotropic hormone (ACTH) and glucocorticoids. We previously reported that so-called "green odor" inhibits stress-induced activation of the hypothalamo-pituitary-adrenocortical axis (HPA axis) and thereby prevents the chronic stress-induced disruption of the skin barrier. Here, we investigated whether rose essential oil, another sedative odorant, inhibits the stress-induced 1) increases in PVN neuronal activity in rats and plasma glucocorticoids (corticosterone [CORT] in rats and cortisol in humans) and 2) skin-barrier disruption in rats and humans. The results showed that in rats subjected to acute restraint stress, rose essential oil inhalation significantly inhibited the increase in plasma CORT and reduced the increases in the number of c-Fos-positive cells in PVN. Inhalation of rose essential oil significantly inhibited the following effects of chronic stress: 1) the elevation of transepidermal water loss (TEWL), an index of the disruption of skin-barrier function, in both rats and humans and 2) the increase in the salivary concentration of cortisol in humans. These results suggest that in rats and humans, chronic stress-induced disruption of the skin barrier can be limited or prevented by rose essential oil inhalation, possibly through its inhibitory effect on the HPA axis.

Pharmacotherapeutic trends in 2231 psychiatric inpatients with bipolar depression from the International AMSP Project between 1994 and 2009.

BACKGROUND: Pharmacological treatment of bipolar depression is a complex and controversial issue, and its real-world practice remains largely unknown. METHOD: Observational analysis of the pharmacotherapy of 2231 psychiatric inpatients with a current episode of bipolar depression. The study was based on cross-sectional prescription data from European psychiatric hospitals that had been repeatedly collected between 1994 and 2009 through the collaborative Drug Safety in Psychiatry (AMSP) program. RESULTS: Overall 81.3% of patients received antidepressants (AD) (7.8% monotherapy), 57.9% antipsychotics (AP), 50.1% anticonvulsants (AC), 47.5% tranquilizers, and 34.6% lithium (Li). Use over time was stable for AD, decreased for Li, and increased for AC, AP and tranquilizers. Pronounced increases were specifically observed for quetiapine, lamotrigine and valproate. Use of tricyclic AD decreased but its prevalence was still 11.8% in 2009. Venlafaxine was used by 19.5% in 2009. We also observed an increase of polypharmacy combining AD, AP, AC and Li. From 2006 to 2009 37.0% received concomitant treatment with three, and 6.4% even with all four of those drug classes. LIMITATIONS: Observational cross-sectional study without follow-up or additional clinical information. CONCLUSIONS: Monotherapy with antidepressants and any use of tricyclic AD and venlafaxine still has a considerable prevalence in bipolar depression, but this is controversial due to the reported risk of treatment emergent affective switches. Triple and quadruple therapy is not evidence-based but increasingly used in clinical practice. This may reflect an attempt to overcome treatment failure, and further studies should evaluate efficacy and safety of this common practice.

[Medical protection during radiation accidents: some results and lessons of the Chernobyl accident].

Actions of medical radiation protection of liquidators of consequences of on Chernobyl atomic power station accident are analysed. It is shown, that during the early period of the accident medical protection of liquidators was provided by administration of radioprotectors, means of prophylaxis: of radioactive iodine incorporation and agent for preventing psychological and emotional stress. When carrying out decontamination and regenerative works, preparations which action is caused by increase of nonspecific resistance of an organism were applied. The lessons taken from the results of the Chernobyl accident, have allowed one to improve the system of medical protection and to introduce in practice new highly effective radioprotective agents.

[Management of the violent or agitated patient]. / Manejo de paciente agitado ou agressivo.

OBJECTIVE: To review current data about the management of agitated or aggressive patients. METHOD: Through a search of databases (PubMed and Web of Science), empirical articles and reviews about pharmacological and non-pharmacological interventions for the management of agitation and /or violence were identified. RESULTS: The non-pharmacological management of agitation/aggression encompasses the organization of space and appropriateness of behavior and attitudes of health professionals. The main goal of pharmacological management is rapid tranquilization aimed at reducing symptoms of agitation and aggression, without the induction of deep or prolonged sedation, keeping the patient calm, but completely or partially responsive. Polypharmacy should be avoided, and doses of medications should be as small as possible, adjusted according to clinical need. Intramuscular administration of medication should be considered as a last resort and the options for the use of antipsychotics and benzodiazepines are described and commented. The physical management by means of mechanical restraint may be necessary in violent situations where there is risk to the patient or staff, and must meet strict criteria. CONCLUSION: Procedures must be carefully implemented to avoid physical and emotional complications for patients and staff.

Manejo de paciente agitado ou agressivo / Management of the violent or agitated patient

OBJETIVO: Revisar as medidas preconizadas para o manejo de pacientes agitados ou agressivos. MÉTODO: Por meio de uma busca em bancos de dados (PubMed e Web of Science) foram identificados artigos empíricos e revisões sobre intervenções farmacológicas e não farmacológicas para o manejo de agitação e/ou violência. RESULTADOS: O manejo não farmacológico de agitação/agressão engloba a organização do espaço físico e a adequação de atitudes e comportamentos dos profissionais de saúde. O objetivo principal do manejo farmacológico é a tranquilização rápida, buscando a redução dos sintomas de agitação e agressividade, sem a indução de sedação profunda ou prolongada, mantendo-se o paciente tranquilo, mas completa ou parcialmente responsivo. A polifarmácia deve ser evitada e as doses das medicações devem ser o menor possível, ajustadas de acordo com a necessidade clínica. A administração intramuscular de medicação deve ser considerada como última alternativa e as opções de uso de antipsicóticos e benzodiazepínicos são descritas e comentadas. O manejo físico, por meio de contenção mecânica, pode ser necessário nas situações de violência em que exista risco para o paciente ou equipe, e deve obedecer a critérios rigorosos. CONCLUSÃO: Os procedimentos devem ser cuidadosamente executados, evitando complicações de ordem física e emocional para pacientes e equipe.

OBJECTIVE: To review current data about the management of agitated or aggressive patients. METHOD: Through a search of databases (PubMed and Web of Science), empirical articles and reviews about pharmacological and non-pharmacological interventions for the management of agitation and /or violence were identified. RESULTS: The non-pharmacological management of agitation/aggression encompasses the organization of space and appropriateness of behavior and attitudes of health professionals. The main goal of pharmacological management is rapid tranquilization aimed at reducing symptoms of agitation and aggression, without the induction of deep or prolonged sedation, keeping the patient calm, but completely or partially responsive. Polypharmacy should be avoided, and doses of medications should be as small as possible, adjusted according to clinical need. Intramuscular administration of medication should be considered as a last resort and the options for the use of antipsychotics and benzodiazepines are described and commented. The physical management by means of mechanical restraint may be necessary in violent situations where there is risk to the patient or staff, and must meet strict criteria. CONCLUSION: Procedures must be carefully implemented to avoid physical and emotional complications for patients and staff.

Clinical review of treatment options for select nonmotor symptoms of Parkinson's disease.

BACKGROUND: Parkinson's disease (PD) is associated with a host of nonmotor symptoms, including psychosis, cognitive impairment, depression, sleep disturbance, swallowing disorders, gastrointestinal symptoms, and autonomic dysfunction. The nonmotor symptoms of PD have the potential to be more debilitating than the motor features of the disorder. OBJECTIVE: The aim of this article was to review treatment options for the nonmotor manifestations of PD, including pharmacologic and nonpharmacologic interventions. METHODS: The PubMed and MEDLINE databases were searched for articles published in English between January 1966 and April 2010, using the terms Parkinson's disease, nonmotor, psychosis, hallucination, antipsychotic, cognitive impairment, dementia, depression, sleep disturbance, sleepiness, REM (rapid eye movement) sleep behavior disorder, dysphagia, swallowing disorder, sialorrhea, gastrointestinal, constipation, autonomic dysfunction, orthostatic hypotension, gastroparesis, erectile dysfunction, sexual dysfunction, and urinary dysfunction. Articles were selected for review if they were randomized controlled trials (RCTs), meta-analyses, or evidence-based reviews of treatment of patients with PD, and/or expert opinion regarding the treatment of nonmotor symptoms of PD. RESULTS: A total of 148 articles, including RCTs, meta-analyses, and evidence-based reviews, were included in this review. The treatment of hallucinations or psychosis in PD should include a stepwise reduction in medications for motor symptoms, followed by the use of quetiapine or clozapine. Dementia may be treated with acetylcholinesterase inhibitors. Evidence is lacking concerning the optimal pharmacologic treatment for depression in PD, with expert opinions indicating selective serotonin reuptake inhibitors as the antidepressants of choice. However, the largest study to date found nortriptyline therapy to be efficacious compared with placebo, whereas paroxetine controlled release was not. A variety of sleep disturbances may plague a person with PD, and treatment must be individualized to the patient's specific sleep disturbance pattern and contributing factors. Swallowing disorders may lead to aspiration and pneumonia, and patients with dysphagia should be referred to a speech therapist for further evaluation and treatment. Orthostasis may be treated with nonpharmacologic interventions as well as pharmacologic treatments (eg, fludrocortisone, midodrine, indomethacin). Other autonomic symptoms are managed in a manner similar to that in patients without PD, although careful attention must be aimed at avoiding dopamine-blocking therapies in the treatment of gastrointestinal dysfunction and gastroparesis. CONCLUSIONS: Various pharmacologic and nonpharmacologic strategies are available for the management of the nonmotor symptoms of PD. The challenges associated with nonmotor symptoms must not be forgotten in light of the motor symptoms of PD, and treatment of nonmotor symptoms should be encouraged.