The aldosterone receptor antagonist spironolactone prevents peritoneal inflammation and fibrosis.

Peritoneal fibrosis is a complication of patients with long-term continuous ambulatory peritoneal dialysis (CAPD). Reports have indicated that angiotensin (Ang) II may correlate with the development of peritoneal fibrosis. However, it is unknown whether aldosterone also has a role in the development of peritoneal inflammation and fibrosis. The aim of the present study was to clarify the role of aldosterone in peritoneal inflammation and fibrosis. A rat model of peritoneal inflammation and fibrosis was established by daily intraperitoneal injection of dialysates and lipopolysaccharide in a 4-day interval over a period of 7 days. The animals were randomly assigned to five groups as follows: control (C); peritoneal dialysis (PD); peritoneal dialysis-spironolactone (PD-S); peritoneal dialysis-cilazapril (PD-C); and peritoneal dialysis-spironolactone-cilazapril (PD-SC). After 30 days, the TGF-ß1 concentration in dialysates from all treatment groups was determined by ELISA. The histopathology of the parietal peritoneum was examined, and the expression of MCP-1, c-Jun, fibronectin (FN) and TGF-ß1 in the abdominal membrane was determined by immunohistochemistry. Mineralocorticoid receptor (MR), 11ß-hydroxysteroid dehydrogenase type 2 (11ß-HSD2) and CYP11B2 (aldosterone synthase) were analyzed by real time-PCR. Collagen deposition was significantly higher in PD compared with the other groups. The expression of MR, 11ß-HSD2 and CYP11B2 was significantly higher in PD compared with the other groups. Spironolactone and/or cilazapril treatment partially ablated the increase in monocyte chemoattractant protein (MCP)-1, p-c-Jun, transforming growth factor (TGF)-ß1, FN, MR, 11ß-HSD2 and CYP11B2. Furthermore, treatment with spironolactone and/or cilazapril also reduced the infiltration of CD-4- and ED-1-positive cells in rat peritoneal tissues after peritoneal fibrosis. Exogenous aldosterone may have a key role in the development of peritoneal inflammation and fibrosis. Spironolactone decreased peritoneal inflammation and fibrosis, which was associated with reduced secretion from peritoneal macrophages, inactivation of the c-Jun N-terminal kinase (JNK) pathway and subsequent downregulation of the expression of TGF-ß1.

Common medications among dental outpatients: considerations in general dental practice.

OBJECTIVES: To provide information about the most common medications listed as being taken by dental patients presenting to an outpatient setting at a tertiary institution and to establish a list of the most common medications for review for the general dental practitioner. METHODS: A retrospective review was undertaken of 300 dental outpatient notes chosen from patients seen in the urgent dental care and exodontia clinics at the School of Dentistry in Dunedin. Data were recorded on patient age, medication list reported at the time of presentation and the number of medications. The ten most common medications encountered were listed in order of frequency, along with the ten most common prescription medications and the most common supplements or alternative remedies. A concise pharmacological synopsis for each of the ten most common medications was then presented as a review. RESULTS: The age range of patients was from 18 to 88 years, with a mean age of 43.2 years (median age 41 years). More than one-quarter were aged 20-29 years. Some 56% of patients reported taking at least one medication at the time of presentation. The greatest number of medications being taken by an individual patient was 15. Of 138 different medications identified, the most commonly reported included aspirin, paracetamol and omeprazole. A list of the ten most common medications was established for concise review, in order to outline aspects important to the general dental practitioner. CONCLUSIONS: This study provides information on the most common medications reported among dental outpatients presenting to a tertiary institution and highlights the need for general dental practitioners to be knowledgeable about them and their impact on dental treatment.

Effects of bisoprolol and cilazapril on the central retinal artery blood flow in patients with essential hypertension--preliminary results.

BACKGROUND: A growing body of evidence suggests that effective blood pressure reduction may inhibit the progression of microvascular damage in patients with essential arterial hypertension. However, the potential influence of anti-hypertensive drugs on ocular circulation has not been studied sufficiently. PURPOSE: The aim of our study was to evaluate the effects of anti-hypertensive therapy on blood flow in the central retinal artery in patients with systemic arterial hypertension. MATERIAL AND METHODS: Twenty patients with essential arterial hypertension, aged 32-46 years, were examined with Doppler ultrasonography (10 MHz ultrasound probe). Blood flow velocities, pulsatility, and vascular resistance were determined before and 3 hours after systemic application of either bisoprolol 5 mg or cilazapril 2.5 mg. RESULTS: Administered bisoprolol significantly decreased maximum (9.8 ± 0.5 cm/s versus 8.5 ± 0.6 cm/s; P < 0.05) and minimum (2.75 ± 0.19 cm/s versus 1.75 ± 0.27 cm/s; P < 0.02) velocity, increased the Pourcellot's index (0.71 to 0.79; P < 0.05) in central retinal artery. There were no statistically significant changes in central retinal artery blood flow after administration of cilazapril. CONCLUSION: Systemic application of beta-blockers may unfavourably disturb the ocular blood flow.

Combination of an ACE inhibitor and indapamide improves blood pressure control, but attenuates the beneficial effects of ACE inhibition on plasma adiponectin in patients with essential hypertension.

BACKGROUND: Antihypertensive agents differentially influence the plasma adiponectin concentration and the effects of fixed-dose combination regimens remain unclear. The influence of a combination of an angiotensin-converting enzyme inhibitor (ACEI) and a thiazide-type diuretic or an ACEI alone on plasma adiponectin concentrations in patients with essential hypertension was evaluated in the present study. METHODS AND RESULTS: After a 2-week placebo run-in phase, 30 patients with essential hypertension were randomized to receive preterax (2 mg perindopril/0.625 mg indapamide) or cilazapril (2.5 mg) once daily for 12 weeks. Plasma adiponectin and insulin concentrations were measured before and after treatment. Insulin resistance was measured by homeostasis assessment index (HOMA-IR). Treatment with preterax (P=0.003) and cilazapril (P=0.031) significantly reduced systolic blood pressure (BP), but only preterax reduced diastolic BP (P=0.024). Cilazapril treatment significantly increased the plasma adiponectin concentration (P=0.025) and reduced plasma triglycerides (P=0.041), whereas preterax treatment increased the plasma insulin concentration (P=0.041) and tended to increase HOMA-IR. CONCLUSIONS: The combination of an ACEI and indapamide improved BP control, but attenuated the beneficial effects of ACE inhibition on plasma adiponectin in patients with essential hypertension. Such a combination may be best reserved for improved BP control rather than for metabolic protection in clinical hypertension.

Combination therapy of prednisone and ACE inhibitor versus ACE-inhibitor therapy alone in patients with IgA nephropathy: a randomized controlled trial.

BACKGROUND: Recent studies have shown that both steroids and angiotensin-converting enzyme (ACE) inhibitors improve kidney survival and decrease proteinuria in patients with immunoglobulin A nephropathy. In this study, we aim to investigate whether the addition of steroids to ACE-inhibitor therapy produces a more potent antiproteinuric effect and better protection of kidney function than an ACE inhibitor alone. STUDY DESIGN: Randomized controlled trial. SETTING & PARTICIPANTS: Patients with biopsy-proven immunoglobulin A nephropathy with proteinuria of 1 to 5 g/d of protein. INTERVENTION: 63 patients were randomly assigned to either cilazapril alone (ACE-inhibitor group; n = 30) or steroid plus cilazapril (combination group; n = 33). OUTCOMES & MEASUREMENTS: The primary end point was kidney survival, defined as a 50% increase in baseline serum creatinine level. RESULTS: After follow-up for up to 48 months, 7 patients in the ACE-inhibitor group (24.1%) reached the primary end point compared with 1 patient (3%) in the combination group. Kaplan-Meier kidney survival was significantly better in the combination group than the ACE-inhibitor group after 24 and 36 months (96.6% versus 75.7%, 96.6% versus 66.2%; P = 0.001). Urine protein excretion significantly decreased in patients in the combination group compared with the ACE-inhibitor group (time-average proteinuria, 1.04 +/- 0.54 versus 1.57 +/- 0.86 g/d of protein; P = 0.01). Multivariate analysis showed that combination treatment (hazard ratio, 0.1; 95% confidence interval, 0.014 to 0.946) and time-average proteinuria (hazard ratio, 14.3; 95% confidence interval, 2.86 to 71.92) were independent predictors of kidney survival. LIMITATIONS: Small sample size, a single center, and slight imbalances at baseline. CONCLUSIONS: Our results suggest that the addition of steroid to ACE-inhibitor therapy provided additional benefit compared with an ACE inhibitor alone. However, this was a pilot study with a small number of participants achieving the end points, and thus further validation is necessary.

Efficacy of a very-low-dose combination of perindopril and indapamide--preterax compared with cilazapril monotherapy in patients with inadequate blood pressure control--a randomized, double-blind, add-on study.

BACKGROUND: Combined regimen may be superior to monotherapy in blood pressure (BP) control. Since BP control is critically related to cardiovascular mortality and morbidity in hypertensive patients, this study aimed to evaluate the efficacy and safety of a low-dose combined regimen of preterax compared with cilazapril monotherapy for better BP control in treated hypertensive patients. METHODS: Stable hypertensive patients were evaluated if their systolic BP (SBP) was > 130 mmHg and/or diastolic BP (DBP) was > 85 mmHg even with up to 2 antihypertensive drugs. Patients were excluded if they were on angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers or a diuretic. They were then randomized to receive either preterax (perindopril 2 mg and indapamide 0.625 mg) or cilazapril 2.5 mg once daily in a double-blind fashion for a period of 12 weeks after a 2-week placebo run-in phase. Sitting BP was recorded and the safety and efficacy were evaluated at each visit every 4 weeks. Response was defined as positive if SBP was < or = 140 mmHg and DBP was < or = 90 mmHg at the last visit or there was > 20 mmHg reduction in SBP and/or > 10 mmHg reduction in DBP using either treatment. Plasma biochemical analysis was performed both before and after the treatment. RESULTS: Among the 47 patients initially enrolled, 41 completed the study (21 in the preterax group, 20 in the cilazapril group). There was no difference in the number of adverse events between the 2 groups. SBP was significantly reduced by preterax (13.43 +/- 12.48mmHg, p < 0.0001) and cilazapril (9.00 +/- 13.75 mmHg, p < 0.05). However, DBP was significantly reduced only by preterax (7.67 +/- 9.40 mmHg, p = 0.0009) but not by cilazapril (3.60 +/- 8.37 mmHg, p > 0.05). The response rate was significantly higher to preterax (100%) than to cilazapril (70%) (p = 0.0086). CONCLUSION: Though similar in safety, combined regimen preterax was more effective than cilazapril to facilitate adequate BP control in already-treated hypertensives. It can be added on to other antihypertensives for better BP control in clinical hypertension.

Reversible posterior encephalopathy syndrome in systemic lupus erythematosus and lupus nephritis.

Reversible posterior encephalopathy syndrome (RPES) is a clinical entity characterized with headache, nausea, vomiting, seizures, consciousness disturbance, and frequently visual disorders associated with neuroradiological findings, predominantly white matter abnormalities of the parieto-occipital lobes. The central nervous system manifestations of systemic lupus erythematosus (SLE) are highly diverse. However, SLE-associated RPES has been seldom reported. Here, we report a case with RPES in SLE and lupus nephritis with exclusive involvement of parietal and occipital cortices. A systematic review of the literature on the pathogenesis and treatment of SLE-associated RPES is included.

Triple pharmacological blockade of the renin-angiotensin-aldosterone system in nondiabetic CKD: an open-label crossover randomized controlled trial.

BACKGROUND: Agents inhibiting the renin-angiotensin-aldosterone (RAAS) system have an important role in slowing the progression of chronic kidney disease. We evaluated the hypothesis that the addition of an aldosterone receptor antagonist to an angiotensin-converting enzyme (ACE) inhibitor and angiotensin II type 1 (AT-1) receptor blocker (ARB) (triple RAAS blockade) may provide an additional benefit compared with an ACE inhibitor and ARB (double RAAS blockade). DESIGN: Randomized open controlled crossover study. SETTING & PARTICIPANTS: 18 whites (7 women, 11 men) from the Outpatient Department of Nephrology with chronic nondiabetic proteinuric kidney diseases, mean age 42.4 +/- 1.9 years (SEM). INTERVENTIONS: In the 8-week run-in period, all participants received the ACE inhibitor cilazapril (5 mg), the ARB telmisartan (80 mg), and the diuretic hydrochlorothiazide (12.5 mg) as double RAAS blockade to achieve the target blood pressure of less than 130/80 mm Hg. Participants were then randomly assigned to 2 treatment sequences, either the addition of spironolactone (25 mg) (triple RAAS blockade) through 8 weeks followed by double RAAS blockade through 8 weeks (sequence 1) or double RAAS blockade followed by triple RAAS blockade (sequence 2). MAIN OUTCOME MEASURES: 24-hour urine protein excretion (primary end point) and markers of tubular injury and fibrosis (secondary end points). Analysis was performed using analysis of variance for repeated measurements. RESULTS: At baseline, mean serum creatinine level was 1.16 +/- 0.09 mg/dL (103 +/- 8 micromol/L), estimated glomerular filtration rate was 107.8 mL/min (95% confidence interval, 93 to 140.9 [1.8 mL/s; 95% confidence interval, 1.55 to 2.35; Cockcroft-Gault formula), and 24-hour mean proteinuria was 0.97 +/- 0.18 g. Mean urine protein excretion was 0.7 g/24 h (95% confidence interval, 0.48 to 0.92) less after triple RAAS blockade than after double RAAS blockade (P = 0.01), without change in blood pressure. Urine excretion of N-acetyl-beta-d-glucosaminidase (P = 0.02) and amino-terminal propeptide of type III procollagen (P = 0.05) also significantly decreased. Potassium levels increased significantly after triple therapy (P = 0.02). However, no patient was withdrawn because of adverse effects. LIMITATIONS: Absence of blinding, small sample size, short treatment period, absence of histological assessment. CONCLUSIONS: Administration of an aldosterone receptor antagonist in addition to double RAAS blockade with an ACE inhibitor and ARB may slow the progression of chronic kidney disease. Additional studies are necessary to confirm this result.

Blood pressure and cardiorenal responses to antihypertensive therapy in obese women.

OBJECTIVE: Blood pressure (BP) and target organ responses to antihypertensive drugs are not well established in hypertensive obese patients. This study is aimed at evaluating the effects of obesity and adiposity distribution patterns on these responses. METHODS: 49 hypertensive obese women were designated to different groups according to waist to hip ratio measurements--37 with troncular and 12 with peripheral obesity. Patients were treated for 24-weeks on a stepwise regimen with cilazapril alone or a cilazapril/hydrochlorothiazide/amlodipine combination therapy to achieve a BP lower than 140/90 mmHg. Ambulatory blood pressure monitoring (ABPM), echocardiography, and albuminuria were assessed before and after the intervention. RESULTS: After 24 weeks, weight loss was less than 2% in both groups. ABPM targets were achieved in 81.5% of patients upon a combination of 2(26.5%) or 3(55.1%) drugs. Similar reductions in daytime-SBP/DBP: -22.5/-14.1(troncular obesity)/-23.6/-14.9 mmHg (peripheral obesity) were obtained. Decrease in nocturnal-SBP was greater in troncular obesity patients. Upon BP control, microalbuminuria was markedly decreased, while only slight decrease in left ventricular mass was observed for both groups. CONCLUSIONS: In the absence of weight loss, most patients required combined antihypertensive therapy to control their BP, regardless of their body fat distribution pattern. Optimal target BP and normal albuminuria were achieved in the group as a whole and in both obese patient groups, while benefits to cardiac structure were of a smaller magnitude.

Short-term effects of cilazapril and atenolol on P-wave dispersion in patients with hypertension.

INTRODUCTION: P-wave dispersion (PWD) has been shown to be a non-invasive electrocardiographic predictor for development of atrial fibrillation (AF). Thus, it may be possible to decrease AF risk through improvement in PWD. Our objective was to compare the effects of cilazapril and atenolol on P-wave duration and dispersion in patients with hypertension. METHODS: A total of 38 newly diagnosed hypertensive patients were enrolled in the study. The patients were randomly assigned to receive treatment with either cilazapril (5 mg) or atenolol (50 mg). Doppler echocardiographic examination, P-wave durations and PWD were measured before and 1 mo after treatment RESULTS: Both drugs reduced blood pressure significantly (P<0.001). Posttreatment heart rate was significantly lower in the atenolol group (P=0.01). The change in maximum P-wave duration was not significant. However, both agents decreased PWD (P=0.001 and P<0.001) and increased the minimum P-wave duration (P=0.004 and P=0.02). CONCLUSION: Both cilazapril and atenolol treatments resulted in improvement in PWD.

Blood pressure and cardiorenal responses to antihypertensive therapy in obese women

OBJECTIVE: Blood pressure(BP) and target organ responses to antihypertensive drugs are not well established in hypertensive obese patients. This study is aimed at evaluating the effects of obesity and adiposity distribution patterns on these responses. METHODS: 49 hypertensive obese women were designated to different groups according to waist to hip ratio measurements - 37 with troncular and 12 with peripheral obesity. Patients were treated for 24-weeks on a stepwise regimen with cilazapril alone or a cilazapril/hydrochlorothiazide/amlodipine combination therapy to achieve a BP lower than 140/90mmHg. Ambulatory blood pressure monitoring (ABPM), echocardiography, and albuminuria were assessed before and after the intervention. RESULTS: After 24 weeks, weight loss was less than 2 percent in both groups. ABPM targets were achieved in 81.5 percent of patients upon a combination of 2(26.5 percent) or 3(55.1 percent) drugs. Similar reductions in daytime-SBP/DBP: -22.5/-14.1(troncular obesity) / -23.6/-14.9mmHg (peripheral obesity) were obtained. Decrease in nocturnal-SBP was greater in troncular obesity patients. Upon BP control, microalbuminuria was markedly decreased, while only slight decrease in left ventricular mass was observed for both groups. CONCLUSIONS: In the absence of weight loss, most patients required combined antihypertensive therapy to control their BP, regardless of their body fat distribution pattern. Optimal target BP and normal albuminuria were achieved in the group as a whole and in both obese patient groups, while benefits to cardiac structure were of a smaller magnitude.

As respostas pressórica e de órgãos-alvo mediante o tratamento anti-hipertensivo medicamentoso, não estão bem estabelecidas em pacientes obesos hipertensos. O presente estudo tem por objetivo avaliar as repercussões da obesidade e da distribuição de gordura corporal sobre estas respostas. MÉTODOS: Foram avaliadas 49 mulheres obesas hipertensas, separadas em subgrupos com distribuição troncular (n = 37) e periférica (n = 12) de gordura, de acordo com a distribuição cintura/quadril. As pacientes foram tratadas por 24 semanas com um regime anti-hipertensivo escalonado, iniciando-se com cilazapril e adicionando-se na seqüência, hidroclortiazida e amlodipina, com alvo pressórico inferior a 140 x 90 mmHg. Foram realizados MAPA, ecocardiograma e microalbuminuria antes e após o tratamento. RESULTADOS: Depois de 24 semanas observou-se perda de peso inferior a 2 por cento em ambos os subgrupos. O controle pressórico à MAPA pode ser observado em 81,5 por cento das pacientes mediante a combinação de duas (26,5 por cento) ou três (55,1 por cento) drogas. Foram obtidas reduções similares nas medidas de PAS/PAD diurnas: -22,5/-14,1(obesas tronculares)/-23,6/-14,9 mmHg (obesas periféricas), enquanto se observou nas obesas tronculares redução maior na PAS noturna. Mediante o controle pressórico, houve redução acentuada da microalbuminúria nos dois subgrupos. Por outro lado, observou-se em ambos, apenas discreta redução na massa ventricular. CONCLUSÕES: Na ausência de perda significativa de peso, e independentemente da distribuição de gordura corporal, a maioria das pacientes obesas necessitou terapia anti-hipertensiva combinada a fim de obter controle pressórico. Em ambos os subgrupos foram alcançados níveis adequados de pressão arterial e redução satisfatória da microalbuminúria, ao passo que os benefícios para a regressão estrutural cardíaca foram menores.

Hyperbaric oxygen treatment augments the efficacy of cilazapril and simvastatin regimens in an experimental nephrotic syndrome model.

BACKGROUND: Oxidative stress plays a role in the mechanism of chronic kidney disease (CKD), and antioxidant regimes are regarded as promising treatment modalities. We compared the effects of cilazapril, simvastatin, and hyperbaric oxygen (HBO) treatment on proteinuria and on oxidative stress in adriamycine (ADR)-induced proteinuria. METHODS: Seventy male Sprague-Dawley rats were housed, and 60 were injected with ADR to induce nephrosis. After the stabilization of proteinuria, rats were treated for 6 weeks with simvastatin (n = 10, 4 mg/kg/day), cilazapril (n = 10, 10 mg/kg/day), HBO (n = 10, 2.8 athmosphere absolute, 90 min/daily), HBO + cilazapril (n = 10), HBO + simvastatin (n = 10), and vehicle (n = 10). After euthanization at 12 weeks, protein carbonyl (PCO), superoxide dismutase (SOD), and glutathion peroxidase (GPx) levels were analyzed from tissues. The histological alterations in the kidneys were determined by semiquantitative scoring. RESULTS: Protein carbonyl (PCO) levels were higher (p < 0.001), and the GPx and SOD levels were lower (p < 0.001 for all) in the nephrotic rats. Proteinuria was correlated to PCO (r = 0.483), GPx (r = -0.686), or SOD (r = -0.620) (p < 0.001 for all). Superoxide dismutase (SOD) (beta = -0.381, p = 0.02) and GPx (beta = -0.509, p < 0.001) were independently related to proteinuria levels. Both cilazapril and simvastatin significantly improved GPx, SOD, PCO, and proteinuria. When HBO was combined with either drug, the above markers further improved (p < 0.001). Both regimens caused distinct histological features, while the combination of HBO made much significant histological improvement. CONCLUSION: Both cilazapril and simvastatin regimens improve oxidative stress and proteinuria, while the effects significantly increase with the combination of HBO treatment. HBO seems to be a candidate antioxidant strategy in glomerular diseases.

Not all ACE inhibitor related angioedema is always evident: a case which is misdiagnosed as panic attack and speech disorder / No siempre es evidente la relación de los inhibidores ACE con el angioedema: un caso que equivocadamente se diagnosticó de ataque de pánico y trastorno del habla

Angiotensin-converting enzyme (ACE) inhibitors are the most common medications responsible for angioedema. Angioedema is a potentially life threatening conditions especially in geriatric age patients that they have take a several medications include ACE inhibitors and non steroidal anti inflammatory drugs. We present a case an ACE inhibitor induced angioedema that confused many clinical events

Los inhibidores de la enzima conversora de angiotensina (ACE) son los medicamentos más comunes responsables del angioedema. El angioedema es una amenaza potencial de las condiciones de vida, especialmente en pacientes de edad geriátrica que tienen que tomar varios medicamentos incluidos los inhibidores ACE y antiinflamatorios no esteroides. Se presenta un caso de angioedema inducido por un inhibidor ACE que causó muchas confusiones clínicas

A case report of a diabetic nephropathy patient with cirrhotic ascites treated by peritoneal dialysis.

A 64-year-old man was admitted because of abdominal fullness, edema and anorexia. He had come to our hospital for treatment of liver cirrhosis and diabetic nephropathy for 1 year. We started diuretics and human albumin intravenous administration. Although the edema disappeared and abdominal fullness improved a little, blood urea nitrogen (BUN) and serum creatinine became elevated, hepatic function deteriorated and he lost his appetite. We consequently started continuous ambulatory peritoneal dialysis (CAPD) in order to control ascites and uremia. Abdominal fullness, appetite and BUN and serum creatinine improved without hepatic function deterioration. It might be important to start CAPD to control ascites although serum creatinine levels might be slightly elevated.

Cognitive function and the emotional state of stroke patients on antihypertensive therapy.

Combined antihypertensive therapy based on 2.5-5 mg of cilazapril (an angiotensin-converting enzyme inhibitor) to normalize arterial pressure (ABP) was studied in 22 patients (12 male, 10 female) aged 49-74 years (mean 63 +/- 7 years) with stroke (18 patients) or transient ischemic attacks (three patients). Magnetic resonance tomography (MRT) including perfusion studies, along with neuropsychological studies and assessment of emotional status (Beck depression inventory, Spielberger anxiety scale), were performed before and after treatment. After six months of treatment, patients showed normalization of ABP (systolic pressure decreased from 154.7 +/- 12 to 128 +/- 23 mmHg, diastolic from 90.3 +/- 9.6 to 79.4 +/- 23 mmHg). There were no side effects and no patient experienced stroke. MRT revealed no signs of new foci and there were no significant changes in brain blood flow. By the end of treatment, improvements in cognitive functions were noted on the Mini Mental State Examination, the 10-word memory test, the Boston naming test, or the Wisconsin card-sorting test, though there were no changes in the patients' emotional status.