Atomoxetine for depression and other neuropsychiatric symptoms in Parkinson disease.

OBJECTIVES: Depression and antidepressant use, especially selective serotonin reuptake inhibitors (SSRIs), are common in Parkinson disease (PD). The objective of this clinical trial was to assess the efficacy of atomoxetine, a selective norepinephrine reuptake inhibitor (SNRI), for the treatment of clinically significant depressive symptoms and common comorbid neuropsychiatric symptoms in PD. METHODS: A total of 55 subjects with PD and an Inventory of Depressive Symptomatology-Clinician (IDS-C) score > or = 22 were randomized to 8 weeks of atomoxetine or placebo treatment (target dosage = 80 mg/day). Depression response (> 50% decrease in IDS-C score or Clinical Global Impression-Improvement [CGI-I] score of 1 or 2) was assessed using intention-to-treat modeling procedures. Secondary outcomes included global cognition, daytime sleepiness, anxiety, apathy, and motor function. RESULTS: There were no between-groups differences in a priori-defined response rates. Using a more liberal response criterion of > 40% decrease in IDS score from baseline, there was a trend (p = 0.08) favoring atomoxetine. Patients receiving atomoxetine experienced significantly greater improvement in global cognition (p = 0.003) and daytime sleepiness (p = 0.001), and atomoxetine was well-tolerated. CONCLUSIONS: Atomoxetine treatment was not efficacious for the treatment of clinically significant depressive symptoms in PD, but was associated with improvement in global cognitive performance and daytime sleepiness. Larger studies of SNRIs in PD for disorders of mood, cognition, and wakefulness are appropriate. CLASSIFICATION OF EVIDENCE: This interventional study provides Class II evidence that atomoxetine (target dosage = 80 mg/day) is not efficacious in improving clinically significant depression in PD.

Validity of the MoCA and MMSE in the detection of MCI and dementia in Parkinson disease.

BACKGROUND: Due to the high prevalence of mild cognitive impairment (MCI) and dementia in Parkinson disease (PD), routine cognitive screening is important for the optimal management of patients with PD. The Montreal Cognitive Assessment (MoCA) is more sensitive than the commonly used Mini-Mental State Examination (MMSE) in detecting MCI and dementia in patients without PD, but its validity in PD has not been established. METHODS: A representative sample of 132 patients with PD at 2 movement disorders centers was administered the MoCA, MMSE, and a neuropsychological battery with operationalized criteria for deficits. MCI and PD dementia (PDD) criteria were applied by an investigator blinded to the MoCA and MMSE results. The discriminant validity of the MoCA and MMSE as screening and diagnostic instruments was ascertained. RESULTS: Approximately one third of the sample met diagnostic criteria for a cognitive disorder (12.9% PDD and 17.4% MCI). Mean (SD) MoCA and MMSE scores were 25.0 (3.8) and 28.1 (2.0). The overall discriminant validity for detection of any cognitive disorder was similar for the MoCA and the MMSE (receiver operating characteristic area under the curve [95% confidence interval]): MoCA (0.79 [0.72, 0.87]) and MMSE (0.76 [0.67, 0.85]), but as a screening instrument the MoCA (optimal cutoff point = 26/27, 64% correctly diagnosed, lack of ceiling effect) was superior to the MMSE (optimal cutoff point = 29/30, 54% correctly diagnosed, presence of ceiling effect). CONCLUSIONS: The Montreal Cognitive Assessment, but not the Mini-Mental State Examination, has adequate psychometric properties as a screening instrument for the detection of mild cognitive impairment or dementia in Parkinson disease. However, a positive screen using either instrument requires additional assessment due to suboptimal specificity at the recommended screening cutoff point.

Delayed chest wall pain after coronary artery bypass.

The author describes a patient who has a successful coronary artery bypass. Six weeks later, after a physical examination of the chest, she had unbearable sharp, stabbing pain around the incision which was not responding to nerve blocks, analgesics, nonsteroidal anti inflammatory agents, and epidural blocks. The pain was responsive to mexilitine and disappeared after three weeks of treatment.

Suggested new operative approach in the treatment of Lutembacher's syndrome, with moderately hypoplastic left ventricle.

Lutembacher's syndrome or ASD secondum and rheumatic mitral stenosis is treated with surgery but in some instances of presence of small left ventricle surgery will lead to death. Nazem's approach which is our Staged Suggested Method has saved several patients with this kind of pathology.

Suggested approach for end to side anastomosis to the abdominal aorta in aorto-femoral bypass grafting for aorto-iliac occlusive disease.

For surgical treatment of aorto-iliac occlusive diseases the prosthetic grafts are used for aorto-femoral bypass in which the end to side anastomoses are done on anterior aspect of aorta. But this approach is leading to some disadvantages caused by gravity or pressure imposed by abdominal viscera and resulting to kinking to the anastomotic area between the vertebral column and viscera which brings about turbulence, platelet aggregation, thrombus formation, and its organization which finally occludes the lumen. Nazem's method of lateral end-to-side anastomosis preferably to the left side of aorta will be without the mentioned bad on sequences, thereby greatly reducing mortality and morbidity. We recommend the interested academic groups use our method, which follows and we welcome them sharing their results with us.

A new approach to aortic annulus enlargement.

Enlargement of the aortic annulus has always been a dilemma. Many techniques have been suggested. We present a new technique which was carried out on 43 patients which caused symptomatic improvement in those patients. The technique includes incising the aortic annulus at both ends of the left coronary cusp or both sides of the left coronary ostium of equal distance. Prosthetic or pericardial patches are used for enlargement. We have had good results with this technique and we believe it is an excellent alternative to prevent late complications on mitral valve.