Psychiatric Medications and Hypertension.

PURPOSE OF REVIEW: The purpose of this review is to provide an overview of psychiatric medications that impact blood pressure in adult patients either as a direct side effect or indirectly, via negative metabolic impact or interactions with other medications. In addition, pertinent interactions between psychiatric medications and antihypertensive agents will be discussed. RECENT FINDINGS: Although the novel intranasal antidepressant, esketamine, has been shown to increase blood pressure shortly after dosing, treatment with antihypertensive medications is not typically required. In addition, no increase in serious adverse cardiac events was reported with this medication. The negative metabolic impact of antipsychotic medications has been shown to occur within the first month of treatment and necessitates early monitoring. When compared with the general population with cardiovascular disease, mortality risk in patients with severe and persistent psychiatric illness is higher, and death occurs 10 years earlier. There are several psychiatric treatments that increase blood pressure directly as well as indirectly, via negative metabolic impact and drug/diet interactions. Fortunately, there are no absolute contraindications for use of any psychiatric medication in patients with pre-existing hypertension. Given data which suggests that patients diagnosed with more severe psychiatric disorders are known to receive inadequate medical care for hypertensive illness and experience increased mortality risk from cardiovascular disease, it is important for all physicians to be aware of the increased risk in this population and for both thorough assessment and treatment to occur.

Serum uric acid is not independently associated with plasma renin activity and plasma aldosterone in hypertensive adults.

BACKGROUND AND AIMS: In experimental investigations conducted in rats, raising serum uric acid (SUA) levels resulted in the stimulation of intrarenal renin expression. Studies in humans exploring the association of SUA with plasma renin activity (PRA) yielded conflicting results. Moreover, little is known about the relationship of SUA with plasma aldosterone concentration (PAC). The study aimed to assess the relationship between SUA levels, PRA, and PAC and the influence of age, gender, body mass index (BMI), and hyperuricemia on these relationships in subjects with essential hypertension (EH). METHODS AND RESULTS: We enrolled 372 hypertensive patients (mean age 45 ± 12 years, men 67%) with uncomplicated EH that was not pharmacologically treated. The study population was divided in tertiles according to SUA levels. While PRA did not differ significantly across the three tertiles, PAC was higher in subjects belonging to the uppermost tertile of SUA than those in the lower ones (p = 0.0429); however, this difference lost statistical significance after adjustment for age, sex, BMI, and serum creatinine. Univariate correlation analyses showed significant associations of SUA with PRA (r = 0.137; p = 0.008) and PAC (r = 0.179; p < 0.001). However, these relationships were not significant after correcting for confounding factors in multiple linear regression analyses. We did not observe statistically significant effect modification by gender, age, BMI, and hyperuricemia. CONCLUSION: SUA levels are weakly associated with PRA and PAC in adults with untreated EH. These relationships were lost after adjustment for age, sex, BMI, and serum creatinine.

Can immune disorders influence therapeutic approaches in treatment of epilepsy among neurologists? A first cooperative national recognition in Italy.

Functional disturbances of the immune system have been detected more often among persons affected by epilepsy than in the general population. In the February-July period of 2007 a specific questionnaire on the relationship between epilepsy and immunological response was sent to 27 specialized Centres for Epilepsy in nine Italian regions. 15,388 epileptic patients attended twenty-seven Centers during this six-month period. 3.3 percent (n=502) of these patients suffered an immune disease. This is the first National survey on the relationship between epilepsy and immunological response in current clinical practice.

99mTc-HMPAO brain SPECT in the monitoring of cerebral vasculitis therapy. / 99mTc-HMPAO SPECT cerebral en la monitorización de la terapia de vasculitis.

OBJECTIVE: The central nervous system (CNS) may be involved in a variety of inflammatory diseases of the blood vessels, generally known as vasculitis. The clinical diagnosis of such involvement in early stages is difficult, since a mild cognitive impairment can be the only symptom. It was hypothesized that brain-perfusion SPECT would be able to reveal CNS involvement and to monitor the course of the disease. The purpose of this study was assess if and when an improvement of cerebral perfusion can be registered by SPECT during the follow-up of these diseases. MATERIAL AND METHODS: Eighteen patients affected by Systemic Lupus Erythematosus (SLE), 22 by undifferentiated vasculitis (UV), 5 by Behcet's disease (BD) and 5 by primary Sjogren's Syndrome (pSS) were enrolled in this prospective study. A 99mTc-HMPAO brain perfusion SPECT was performed before the treatment and was repeated during the follow-up at different time intervals. Image analysis was performed on 10 cerebral areas using a specific software. RESULTS: In the SLE patients, no significant improvement of brain perfusion was found. On the contrary, in the UV the cerebral uptake of the tracer significantly improved from the twenty-fourth month (18/22 patients). Patients with BD showed an improvement of scintigraphic findings (5/5 patients), while a similar result was obtained only in 2 of the patients with pSS. CONCLUSIONS: In conclusion, brain SPECT seems to be able to monitor the disease in UV, indicating the moment when an improvement of the cerebral perfusion is achieved. In SLE patients this scintigraphic technique did not show a significant improvement in CNS perfusion.

Average real variability of 24-h systolic blood pressure is associated with microalbuminuria in patients with primary hypertension.

Limited and conflicting data are available about the association between short-term blood pressure (BP) variability and urinary albumin excretion rate (uAER). The objective of our study was to analyze the relationships between microalbuminuria (MAU), defined as an uAER between 20 and 200 µg min(-1), and short-term BP variability (BPV), assessed as average real variability (ARV), weighted s.d. of 24-h BP and as s.d. of daytime and night-time BP. The study population consisted of 315 untreated essential hypertensives with normal estimated glomerular filtration rate (>60 ml min(-1) per 1.73 m(2)), who underwent 24-h ambulatory BP monitoring and 24-h uAER determination. MAU was detected in 82 (26%) patients. ARV of 24-h systolic BP (SBP) was significantly higher in patients with MAU (9.8 (8.5-11.1) mm Hg) when compared with those without it (9.1 (8-10.2) mm Hg; P=0.007). This difference held (P=0.026) after adjustment for age, mean levels of BP and other potential confounders by analysis of covariance. A statistically significant correlation was also found between ARV of 24-h SBP and uAER (r=0.17; P=0.003). This association remained significant (ß=0.15; P=0.01), also taking into account the effect of 24-h average systolic and diastolic BP, age, gender, diabetes, serum uric acid, triglycerides, estimated glomerular filtration rate in multiple regression analyses. All the other indices of short-term BPV tested were not independently associated with MAU. Our results seem to suggest that in essential hypertension, short-term BPV, only when estimated by ARV of 24-h SBP, is independently associated with MAU.

Reaction of melatonin with lipoperoxyl radicals in phospholipid bilayers.

Melatonin, at 5 to 500 microM was incorporated in unilamellar soybean phosphatidylcholine (PC) liposomes, the peroxidation of which was induced by 2,2'-azobis (2-amidinopropane-hydrochloride) (AAPH), and measured as production of conjugated diene lipid hydroperoxides. Concentration as low as 5 and 10 microM were poorly effective in reducing lipid peroxidation. Melatonin at 30 to 500 microM caused short inhibition periods, increasing with, but not linearly related to concentration, with a concurrent net decrease of the propagation rate. The time course of melatonin oxidation, measured as loss of fluorescence, was studied during the AAPH-stimulated peroxidation of soybean PC liposomes, or when melatonin was incorporated in nonperoxidable unilamellar dimirystoyl phosphatidylcholine (DMC) liposomes. Consumption kinetics of 30 microM melatonin were linear with time in DMC liposomes and disappearance of melatonin occurred at a rate of 0.058 M(-8) s(-1). On the other hand, the consumption of melatonin during the oxidation of soybean PC liposomes, was not linear with time. The rate of disappearance was calculated as 0.19 M(-8) s(-1) at the beginning of the propagation phase, then it slowed down to reach the same rate observed in DMC liposomes. This evidence suggests a reaction with lipid-derived peroxyl radicals, possibly in addition to reaction with peroxyl radicals derived from AAPH. Scavenging of lipoperoxyl radicals by melatonin was also evident in experiments where melatonin was incorporated in multilamellar soybean PC liposomes and peroxidation was initiated by 2,2 '-azobis (2,4-dimethyl-valeronitrile). The antioxidant activity of melatonin in soybean PC liposomes is much lower than that of alpha-tocopherol, under comparable assay conditions. However, a combination of melatonin and alpha-tocopherol, at 5 microM, resulted in a synergistic antioxidant effect. Time course of alpha-tocopherol consumption, monitored in the absence and in the presence of melatonin, showed a significant decrease of the consumption rate when compounds were combined, indicating some protection by melatonin. Regeneration mechanisms were not evident and depletion of alpha-tocopherol was coincident with the inhibition time.

Guidelines for adolescent health research: a position paper of the society for adolescent medicine.

Their ambiguous legal and ethical status has become a barrier to adolescents' appropriate involvement in research from which they may benefit and which is needed to improve adolescent health care and to inform health policy. Involvement of adolescents in research should be based on a scientific and empathetic understanding of their developing capabilities and a careful assessment of risks and benefits. The important role of parents and communities as protectors of adolescents should be respected and enhanced as we acknowledge and respect developing adolescent autonomy. These guidelines provide a framework to interpret the federal regulations for protection of human subjects in light of the unique legal, ethical, developmental, contextual, and racial issues that affect adolescents. The guidelines are designed to protect individual adolescent research subjects and to facilitate important youth research that would promote the health of adolescents.

Structural brain MR imaging changes associated with obsessive-compulsive disorder in patients with multiple sclerosis.

BACKGROUND AND PURPOSE: Psychiatric symptoms occur in approximately 30% of patients with MS. Such symptoms include OCD, which may interfere heavily with the patient's daily life. We hypothesized that the widespread involvement of both GM and WM, which characterizes MS, may be responsible for the occurrence of OCD when specific brain structures are affected. The aim of this study was to evaluate the relationship between GM and WM tissue damage and OCD in patients with MS. MATERIALS AND METHODS: We evaluated 16 patients with relapsing-remitting MS who had been diagnosed with OCD on the basis of the Diagnostic and Statistical Manual of Mental Disorders (4th edition) and 15 age- and sex-matched patients with relapsing-remitting MS with no psychiatric disorders as a CG. The MR study (1.5T) included 3D T1-weighted fast-field echo sequences, DTI (32 directions), and conventional MRI. Images were processed using SPM5, FSL, and Jim 5.0 software to evaluate VBM, TBSS, and global and regional LV, respectively. RESULTS: The VBM analysis revealed a set of clusters of reduced GM volume in the OCD group, compared with the CG, located in the right inferior and middle temporal gyri and in the inferior frontal gyrus. TBSS did not detect any differences in the FA values between the 2 groups; global and regional LV values also did not differ significantly between the 2 groups. CONCLUSIONS: Our study suggests that OCD in MS may be caused by damage in the right frontotemporal cortex.

Financing adolescent health care: the role of Medicaid and CHIP.

Financing health care for adolescents involves a combination of public and private sources of payment and, in the public sector, a combination of insurance coverage and categorical programs. In recent years, the importance of health insurance coverage has increased along with the potential for insuring more adolescents. Medicaid and the new State Children's Health Insurance Program (CHIP) offer numerous options for reducing the proportion of uninsured adolescents and for increasing adolescents' access to necessary health care. This article explores the potential of Medicaid and CHIP for meeting adolescents' needs, the extent to which they have done so already, and the gaps or missing links that remain. It also reviews issues that cut across funding sources related to managed care, consent, and confidentiality.

Synergistic effect of glycolic acid on the antioxidant activity of alpha-tocopherol and melatonin in lipid bilayers and in human skin homogenates.

Considerable interest has been raised concerning the use of natural compounds in preventing skin aging and photoaging. In the idea that the combined action of agents increasing epidermal turnover with antioxidants could be advantageous in cosmetic and therapeutic treatments, we first investigated if alpha-glycolic acid affected or prevented the antioxidant activity of vitamin E and of melatonin, two compounds found beneficial as topical photoprotectant. Assays were carried out in vitro either in a biomimetic liposomal system, or in human skin homogenates. Lipid peroxidation was monitored spectrophotometrically by the time course of lipid hydroperoxide production in liposomes and by formation of TBA reactive substances (TBARS) in skin homogenates. Glycolic acid, at 25 microM to 1 mM, showed a mild, concentration-dependent antioxidant effect in liposomes, as evaluated by a slight decrease of the peroxidation rate, while, at 1 mM, reduced TBARS production in skin homogenates by 14%. Combinations of either vitamin E or melatonin with glycolic acid, in a 1:5 to 1:200 molar ratio, resulted in a clear synergistic protection of liposomes, more evident for the combination of glycolic acid with vitamin E. An amount of synergism up to 250% and up to 80% was evaluated with vitamin E and melatonin, respectively. Consumption rate of vitamin E during peroxidation of liposomes, in the absence or in the presence of glycolic acid, suggests that regeneration of vitamin E may in part explain the observed synergism. Synergistic antioxidant activity between vitamin E and glycolic acid was also observed in skin homogenates, whereas the effect of glycolic acid on the antioxidant activity of melatonin appeared additive. However, the combination of these three compounds inhibited TBARS production almost completely. Our data provide evidence that glycolic acid can strongly potentiate the antioxidant action of melatonin and vitamin E. This may suggest the advantage of combining alpha-glycolic acid with these antioxidants in skin designed preparations, both to improve penetration and availability of antioxidants to epidermal layers and to enhance their protective potential.

Significant bacteriuria has prognostic significance in primary biliary cirrhosis.

Significant bacteriuria in women has been found to be associated with increased mortality in community-based studies. We have previously reported a high prevalence of significant bacteriuria with a high recurrence rate in females with primary biliary cirrhosis (PBC), particularly those with late stage disease on liver biopsy. During a 5-year period we prospectively screened for significant bacteriuria in 187 women with primary biliary cirrhosis, (median follow-up of 47 months, range 1-83). Significant bacteriuria was found in 30 (17%) in their first urine (index bacteriuria), 90 (48%) died and 15 (8%) had liver transplants. Cox's proportional hazard models showed that age, serum bilirubin, ascites and cirrhosis were independent prognostic variables. Index bacteriuria added significantly to this model (P = 0.069) being independent from other variables, with an increased relative hazard for death of 1.65 (65% increase in risk of death) compared to non-bacteriuric patients. This effect was due mainly to non-cirrhotic patients with significant bacteriuria as shown by using multiplicative variables for histological stage and significant bacteriuria. An index of recurrent bacteriuria was significantly increased in patients with index bacteriuria (P less than 0.001) and in those who died or underwent transplantation (P less than 0.001). In this study, significant bacteriuria defined a specific sub-group of PBC patients with an increased risk of death.