Mirtazapine augmentation in the treatment of refractory depression.

BACKGROUND: Pharmacotherapeutic strategies that target specific actions at multiple neuronal receptors or cellular components may offer a superior approach for treatment of refractory depression. Mirtazapine is a novel antidepressant which has a mechanism that involves the enhancement of noradrenergic and serotonergic neurotransmission via blockade of alpha2-adrenergic autoreceptors and heteroreceptors without activity at the serotonin transporter. Mirtazapine is thus a compelling candidate for augmentation treatment in patients who fail to achieve adequate response with other antidepressant medications. METHOD: Twenty patients with DSM-IV major depression or dysthmia who had persistent depressive syndromes despite at least 4 weeks of standard antidepressant pharmacotherapy were given augmentation with mirtazapine (15 to 30 mg p.o. q.h.s.) on an open-label basis. Clinical assessments of status at baseline, 2 weeks, and 4 weeks were used to rate response. RESULTS: Forty-five percent (N = 9) of the sample were responders at 2 weeks. At the 4 week follow-up, 55% (N = 11) were responders, 30% (N = 6) were nonresponders, and 15% (N = 3) had discontinued treatment owing to side effects. Common side effects included weight gain and sedation. CONCLUSION: These data suggest that the addition of mirtazapine may be beneficial for patients who have refractory depression, but side effects are prominent at the doses we used. Controlled trials to further evaluate the efficacy and safety of mirtazapine augmentation are needed.

Relationship of childhood sexual abuse and eating disorders.

OBJECTIVE: To review the literature that has examined the relationship between childhood sexual abuse and the eating disorders. METHOD: Each of the five authors reviewed all identified empirical studies to be certain that inclusion/exclusion criteria were met. Two teams of raters then independently reviewed each study to determine whether it supported any of a series of six hypotheses that had been tested in this literature. RESULTS: This review indicates that childhood sexual abuse is a nonspecific risk factor for bulimia nervosa, particularly when there is psychiatric comorbidity. There is some indication that childhood sexual abuse is more strongly associated with bulimic disorders than restricting anorexia, but it does not appear to be associated with severity of the disturbance. CONCLUSION: Childhood sexual abuse is a risk factor for bulimia nervosa with significant comorbidity. Further study of the nature of this relationship is warranted.

The role of client choice and target selection in self-management therapy for depression in older adults.

In a study designed to maximize the effectiveness of treatment by allowing participants to select the target of treatment, 40 depressed older adults were randomly assigned to a waiting-list control condition or to conditions in which the target of treatment was either chosen or assigned. All participants received self-management therapy and the choice was between changing behavior or changing cognition. It was found that individually administered self-management therapy was effective in treating depression for older adults. There were no differences in outcome between versions of self-management therapy that targeted behavioral or cognitive change. Among those who completed treatment, there were no differences in outcome between those who received a choice and those who did not. Individuals who were given a choice of treatment options, however, were less likely to drop out of treatment prematurely.

[Coronary occlusive disease and carotid stenosis]. / Maladie coronarienne occlusive et sténose des artères carotides.

In around 2.5% of patients with coronary artery diseases (CAOD), considerably occlusive changes in carotid arteries were also registered at the same time. In the period from March 1982 to February 15, 1993, at the University Clinic of Cardiovascular surgery in Novi Sad, a total of 5,701 patients underwent aortocoronary by-pass (ACBG). In 137 (2.4%) patients an additionally endarterectomy of carotid arteries (EAC) were also performed. Bad left ventricle function (EF < 30%) was registered in 30 pts (22%). Endarterectomy on one or more arteries had to be performed in 45% patients because diffuse and distal occlusive changes. Two stage operations were performed in 62 cases. Three stages operations (bilat. EAC) in 24 and simultaneous in 51. Operative mortality (30 days) was registered in 5 (3%) pts. Neurologic deficit (ND) happened in two (1.4%) pts, TIA in 3 pt (2.2%). Comparing our results in simultaneous and stage procedure, operative risk is higher in simultaneous operations, and only in case of unstable angina we prefer simultaneous operations.

Reduplication after right middle cerebral artery infarction.

Reduplication and misidentification syndromes are similar and peculiar phenomena of disorientation and beliefs with delusional qualities. They are more frequent among neurologic and psychiatric patients than previously thought. Organic factors play a definitive role in their occurrence. A case is presented which exemplifies reduplication of place and person, following a right hemisphere focal lesion. Current theories are briefly reviewed and possible roles of nortriptyline therapy and psychological factors are discussed in the pathogenesis of reduplicative phenomena in this patient.

Performance variability as a new theoretical mechanism regarding eating disorders and cognitive processing.

Bulimic (n = 23) and control subjects (n = 28) were compared on four neuropsychological tests and several clinical variables. Between-group differences were observed on neuropsychological measures that reflected marked impulsivity and problem-solving deficits in the bulimics. Additional between-group comparisons, based on the variability of performance on the neuropsychological tests, revealed that bulimics were more variable than controls on approximately 50% of the tests given Performance variability on the remaining two tests was equal across the bulimic and control groups. This represents the first known application of this performance variability analysis in subjects with bulimia nervosa. It is proposed that there may be considerable variability in performance among bulimics and that by examining performance from this "sub-group" perspective may lead to a more analytic understanding of this eating disorder.

Memory and frontal lobe dysfunction in schizophrenia and schizoaffective disorder.

Verbal memory and performance on a number of tests known to be sensitive to lesions that disrupt frontal lobe functioning were studied in patients with schizophrenia or schizoaffective illness. Both patient groups were severely and equally impaired on verbal and design fluency and on the Wisconsin Card Sorting Test, measures that are sensitive to dysfunction of frontal-striatal circuitry. Both patient groups exhibited impaired recall but nearly normal recognition memory, a pattern that is typically observed in frontal and subcortical diseases. Accelerated forgetting was evident on delayed recall tests; the magnitude of this impairment was greater for schizophrenic than for schizoaffective patients. These results suggest that frontal and/or subcortical dysfunction is common to schizophrenia and schizoaffective disorder. A subgroup including the majority of schizophrenic patients, however, exhibit a mild amnesia-like disorder which may result from pathological changes in the structure and function of the temporal lobes or the medial diencephalon.

[Myocardial revascularization using the internal thoracic artery: pro and con]. / Revaskularizacija miokarda unutrasnjom torakalnom arterijom: "pro et contra".

Internal thoracic artery (ITA) has superior histological, physiological and pharmacological properties over the venous grafts, and it is considered to be the graft of choice for myocardial revascularization. It has low incidence of late atherosclerotic lesions, and excellent long-term patency. Usage of ITA yields improved clinical results in all subgroups of patients with coronary artery disease, including patients with poor left ventricular function (EF%), left main stenosis, diffuse coronary artery disease and octogenarians. Since superior long-term results (to be expected only 10-15 years after the operation) may be outweighed with slightly higher incidence of early morbidity and mortality, many cardiac surgeons are reluctant to use it routinely. However, this attitude is difficult to justify, since early operative results in patients that have received ITA graft are superior as well, compared to patients that have received vein grafts only.

[History of surgical treatment of atherosclerosis of the coronary arteries--the first 100 years]. / Istorijat hirurskog lecenja aterosklerotskog oboljenja koronarnih krvnih sudova--prvih 100 godina.

Atherosclerotic coronary artery disease is the most common cause of morbidity and mortality. The incidence of cardiovascular morbidity and mortality has been doubled in our country during the period 1980 through 1996. Surgical treatment of the atherosclerotic coronary artery disease is already a century old, ever since Francois-Franck (in 1899) tried to achieve sympathetic denervation of the cervical ganglion. After the interim period of indirect myocardial revascularization, during the last 30 years, direct surgical revascularization has reached excellent early and long-term results, and became one of the most frequently performed procedures in the surgical practice. Use of arterial grafts and, introduced recently, procedures on the beating heart, minimally invasive procedures and, so called, port-access procedures became a daily routine in many centers. Surgical revascularization of the ischaemic cardiac muscle is the rapidly changing entity, along with diagnostic, technical and other improvements. We present a brief historical overview of the efforts of cardiac surgeons to combat the "disease of the century" atherosclerotic coronary artery disease.