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2.
Anaesthesia ; 75(9): 1153-1163, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32395901

RESUMO

Deep neuromuscular block aims to improve operative conditions during laparoscopic surgery with a lower intra-abdominal pressure. Studies are conflicting on whether meaningful improvements in quality of recovery occur beyond emergence, and whether lower intra-abdominal pressure is achieved. In this pragmatic randomised trial with 1:1 allocation, adults undergoing elective laparoscopic surgery were allocated to moderate neuromuscular block reversed with neostigmine, or deep neuromuscular block reversed with sugammadex. Allocation was revealed to the anaesthetist only. Primary outcome was cognitive recovery of the Postoperative Quality of Recovery Scale, 7 days after surgery. Secondary outcomes included recovery in other domains of the Postoperative Quality of Recovery Scale at 15 min and 40 min; days 1, 3, 7, 14; and 1 and 3 months after surgery. Chi-square test was used for the primary outcome, and generalised linear mixed model for recovery over time between groups. Of 350 participants randomised, 140 (deep) and 144 (moderate) were analysed for the primary outcome. There was no difference in the Postoperative Quality of Recovery Scale cognitive domain at day 7 (deep 92.9% vs. moderate 91.8%, OR 1.164; 95%CI 0.486-2.788, p = 0.826), or at any other time-point. No significant difference was observed for physiological, emotive, activities of daily living, nociception, or overall recovery. Length of stay in the recovery area (mean (SD) deep 108 (58) vs. moderate 109 (57) min, p = 0.78) and hospital (1.8 (1.9) vs. 2.6 (3.5) days, p = 0.019) was not different. Intra-abdominal pressure and surgical operating conditions were not different between groups. Deep neuromuscular block did not improve quality of recovery compared with moderate neuromuscular block in operative laparoscopic surgery over a 1-h duration.


Assuntos
Período de Recuperação da Anestesia , Inibidores da Colinesterase/uso terapêutico , Neostigmina/uso terapêutico , Bloqueio Neuromuscular/métodos , Sugammadex/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente/estatística & dados numéricos , Estudos Prospectivos , Método Simples-Cego
4.
Med Clin North Am ; 104(3): 405-413, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32312406

RESUMO

Older adults, particularly those late in life, are at higher risk for medication misadventure, yet bear the burden of increasing polypharmacy. It is incumbent on practitioners who care for this vulnerable population to use one or more approaches to deprescribe medications that impose a greater burden than benefit, including medically futile medications. It is essential that health care providers use compassionate communication skills when explaining these interventions with patients and families, pointing out that this is a positive, patient-centric intervention.


Assuntos
Estado Terminal/terapia , Pessoal de Saúde/ética , Prescrição Inadequada/efeitos adversos , Assistência Centrada no Paciente/métodos , Idoso , Idoso de 80 Anos ou mais , Inibidores da Colinesterase/uso terapêutico , Comunicação , Desprescrições , Diabetes Mellitus/tratamento farmacológico , Difosfonatos/uso terapêutico , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Feminino , Serviços de Saúde para Idosos , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Prescrição Inadequada/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Assistência Centrada no Paciente/normas , Polimedicação
5.
Medicine (Baltimore) ; 99(15): e19781, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32282741

RESUMO

INTRODUCTION: Surgical stress and pain are potential provoking factors for postoperative myasthenic crisis (POMC). We report the occurrence of early POMC and late deep vein thrombosis (DVT) in a man with myasthenia gravis (MG) undergoing thymectomy, addressing possible link between reversal of opioid overdose with naloxone and the triggering of POMC. PATIENT CONCERNS: A 71-year-old man with impaired renal function (ie, estimated glomerular filtration rate [egfr]: 49.1 mL/min/1.73 m) with diagnosis of MG made 2 months ago was scheduled for thymectomy. After uncomplicated surgery, he experienced opioid overdose that was treated with naloxone. Hyperlactatemia then developed with a concomitant episode of hypertension. Three hours after reversal, he suffered from myasthenic crisis presenting with respiratory failure and difficult weaning from mechanical ventilation. DIAGNOSIS: Stress-induced hyperlactatemia and subsequent myasthenic crisis INTERVENTIONS:: Pyridostigmine and immunosuppressive therapy with prednisolone were initiated. Hyperlactatemia subsided on postoperative day (POD) 5. Tracheal extubation was performed successfully on POD 6. OUTCOMES: During the course of hospitalization, his eGFR (ie, 88.9 mL/min/1.73 m) was found to improve postoperatively. After discharge from hospital, he developed DVT in the left femoral and popliteal veins on POD 24 when he was readmitted for immediate treatment with low-molecular-weight heparin. He was discharged without sequelae on POD 31. There was no recurrence of myasthenic crisis or DVT at 3-month follow-up. CONCLUSIONS: Following naloxone administration, hyperlactatemia may be an indicator of pain-related stress response, which is a potential provoking factor for myasthenic crisis. Additionally, patients with MG may have an increased risk of DVT possibly attributable to immune-mediated inflammation. These findings highlight the importance of perioperative avoidance of provoking factors including monitoring of stress-induced elevations in serum lactate concentration, close postoperative surveying for myasthenic crisis, and early recognition of possible thromboembolic complications in this patient population.


Assuntos
Miastenia Gravis/complicações , Timectomia/efeitos adversos , Trombose Venosa/etiologia , Idoso , Anticoagulantes/administração & dosagem , Anticoagulantes/uso terapêutico , Inibidores da Colinesterase/administração & dosagem , Inibidores da Colinesterase/uso terapêutico , Heparina de Baixo Peso Molecular/administração & dosagem , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Hiperlactatemia/induzido quimicamente , Hiperlactatemia/diagnóstico , Hiperlactatemia/tratamento farmacológico , Hipertensão/induzido quimicamente , Hipertensão/diagnóstico , Imunossupressores/administração & dosagem , Imunossupressores/uso terapêutico , Masculino , Miastenia Gravis/diagnóstico , Miastenia Gravis/cirurgia , Naloxona/efeitos adversos , Antagonistas de Entorpecentes/efeitos adversos , Transtornos Relacionados ao Uso de Opioides/complicações , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Readmissão do Paciente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/patologia , Prednisolona/administração & dosagem , Prednisolona/uso terapêutico , Brometo de Piridostigmina/administração & dosagem , Brometo de Piridostigmina/uso terapêutico , Respiração Artificial/métodos , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapia , Resultado do Tratamento
6.
Arq Neuropsiquiatr ; 78(3): 179-181, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32215460

RESUMO

Currently, pyridostigmine bromide is an indispensable anticholinesterase agent used worldwide to treat patients with Myasthenia Gravis (MG). However, pyridostigmine bromide was unsuccessful in its "pioneering trials" to treat a series of MG patients. There are important historical landmarks before pyridostigmine bromide becomes useful, safe and indispensable for MG therapy. After 70 years of these "pioneering trials", this article reviews some historical aspects related to them, as well as other preliminary trials using pyridostigmine bromide as therapy for MG patients.


Assuntos
Inibidores da Colinesterase/uso terapêutico , Miastenia Gravis/tratamento farmacológico , Brometo de Piridostigmina/uso terapêutico , Humanos
7.
PLoS One ; 15(2): e0227820, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32032361

RESUMO

Cognitive impairment is a common complication observed after a stroke. Currently there are no definitively proven pharmacologic therapies for recovery from post-stroke cognitive impairment and vascular dementia. In this meta-analysis, we evaluated the efficacy and safety of cholinesterase inhibitors in their improvement of cognition in patients with post-stroke cognitive impairment and vascular dementia. We conducted a meta-analysis using seven eligible studies from 305 published articles. We investigated the differences in Mini-Mental State Examination (MMSE) and Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog) scores, before and after cholinergic augmentation in patients with post-stroke cognitive impairment and vascular dementia. MMSE and ADAS-cog scores were also compared during the subsequent follow-up periods. MMSE score of patients with post-stroke cognitive impairment was increased after cholinergic augmentation throughout the 24 weeks with mean differences [MD] of 3.000, 1.732, 1.578 1.516, and 1.222, at 4, 4-8, 8-12, 12-18, and 18-24 weeks, respectively. In addition, ADAS-cog scores decreased at 6, 12, 18, and 24 weeks by pharmaceutical augmentation, but not with placebo with mean differences [MD] of -2.333, -2.913, -2.767, -2.416, and -1.859, respectively. This meta-analysis shows that acetylcholinesterase inhibitors maintain a stable pattern of improved cognitive function in patients with post stroke cognitive impairment and vascular dementia without the increased risk of side effects.


Assuntos
Inibidores da Colinesterase/uso terapêutico , Disfunção Cognitiva/tratamento farmacológico , Disfunção Cognitiva/etiologia , Demência Vascular/tratamento farmacológico , Demência Vascular/etiologia , Acidente Vascular Cerebral/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Doença de Alzheimer/diagnóstico , Inibidores da Colinesterase/efeitos adversos , Inibidores da Colinesterase/farmacologia , Feminino , Humanos , Masculino , Testes de Estado Mental e Demência , Pessoa de Meia-Idade
8.
Geriatr Gerontol Int ; 20(4): 324-328, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32037700

RESUMO

AIM: Alzheimer's disease (AD) is the most common neurodegenerative disease. In 2000, Mendiondo et al. reported on a model predicting that AD progresses at an accelerating rate and cognitive function worsens rapidly. Recently, anti-AD drugs and non-pharmacological intervention have been established, but the effect of intervention is unclear and might depend on the stage of AD progression. Here, we examined the prediction of Mendiondo's model in patients with different severities of AD. METHODS: A total of 163 new outpatients with AD at four memory clinics were retrospectively analyzed. The Revised Hasegawa Dementia Scale (HDS-R) and Mini-Mental State Examination (MMSE) were administered to all AD patients at the first visit and after approximately 12 months. We divided the patients into three groups according to scores at the first visit: mild, moderate and moderate-to-severe. We compared the scores at the first visit with those obtained after 12 months of anti-AD drug and non-pharmacological interventions. RESULTS: The HDS-R score improved from 14.5 to 15.0, and the MMSE score improved from 18.8 to 19.1 after 12 months of intervention. Also, the HDS-R and MMSE scores at the first visit were significantly associated with the annual change in the scores. Among the three groups, lower HDS-R and MMSE scores at the first visit were associated with significantly greater annual improvement in the scores after 12 months of intervention. CONCLUSIONS: Contrary to the prediction of Mendiondo's model, mild or moderate AD progressed more rapidly than moderate-to-severe AD under pharmacological and non-pharmacological interventions. Geriatr Gerontol Int 2020; 20: 324-328.


Assuntos
Doença de Alzheimer/terapia , Idoso , Idoso de 80 Anos ou mais , Inibidores da Colinesterase/uso terapêutico , Cognição/efeitos dos fármacos , Progressão da Doença , Donepezila/uso terapêutico , Feminino , Galantamina/uso terapêutico , Humanos , Japão , Masculino , Memantina/uso terapêutico , Testes de Estado Mental e Demência/estatística & dados numéricos , Estudos Retrospectivos , Rivastigmina/uso terapêutico
9.
BMC Neurol ; 20(1): 10, 2020 Jan 09.
Artigo em Inglês | MEDLINE | ID: mdl-31918679

RESUMO

BACKGROUND: We investigated the potential associations between cerebro-spinal fluid (CSF) levels of phosphorylated tau (P-tau) and total tau (T-tau) with short-term response to cholinesterase inhibitor (ChEI) treatment, longitudinal outcome and progression rates in Alzheimer's disease (AD). METHODS: This prospective, observational study included 129 participants clinically diagnosed with mild-to-moderate AD, who underwent a lumbar puncture. The CSF biomarkers amyloid-ß1-42 (Aß42), P-tau and T-tau were analysed with xMAP technology. Cognitive, global, instrumental and basic activities of daily living (ADL) capacities at the start of ChEI therapy and semi-annually over 3 years were evaluated. RESULTS: All patients had abnormal Aß42 (A+). Fifty-eight individuals (45%) exhibited normal P-tau and T-tau (A+ T- (N)-), 12 (9%) abnormal P-tau/normal T-tau (A+ T+ (N)-), 17 (13%) normal P-tau/abnormal T-tau (A+ T- (N)+) and 42 (33%) abnormal P-tau and T-tau (A+ T+ (N)+). The participants with A+ T+ (N)+ were younger than A+ T- (N)+ at the estimated onset of AD and the initiation of ChEIs. The proportion of 6-month responders to ChEI and deterioration/year after start of treatment did not differ between the AT(N) profiles in any scales. A higher percentage of globally improved/unchanged patients was exhibited in the A+ T- (N)- group after 12, 30 and 36 months of ChEI therapy but not at other assessments. In apolipoprotein E (APOE) ε4-carriers, linear relationships were found between greater cognitive decline/year and higher tau; Mini-Mental State Examination score - T-tau (rs = - 0.257, p = 0.014) and Alzheimer's Disease Assessment Scale-cognitive subscale - P-tau (rs = - 0.242, p = 0.022). A correlation between faster progression in instrumental ADL (IADL) and higher T-tau was also detected (rs = - 0.232, p = 0.028). These associations were not demonstrated in non-ε4-carriers. CONCLUSIONS: Younger age and faster global deterioration were observed in AD patients with pathologic tau and neurodegeneration, whereas more rapid cognitive and IADL decline were related to higher P-tau or T-tau in APOE ε4-carriers only. The results might indicate an association between more pronounced tau pathology/neuronal injury and the APOE ε4-allele leading to a worse prognosis. Our findings showed that the AT(N) biomarker profiles have limited utility to predict AD progression rates and, thus, measure change and interpreting outcomes from clinical trials of future therapies.


Assuntos
Doença de Alzheimer/líquido cefalorraquidiano , Biomarcadores/líquido cefalorraquidiano , Proteínas tau/líquido cefalorraquidiano , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Doença de Alzheimer/tratamento farmacológico , Doença de Alzheimer/genética , Apolipoproteína E4/genética , Inibidores da Colinesterase/uso terapêutico , Progressão da Doença , Feminino , Genótipo , Humanos , Masculino , Fosforilação , Estudos Prospectivos
10.
J Biomed Sci ; 27(1): 18, 2020 Jan 06.
Artigo em Inglês | MEDLINE | ID: mdl-31906949

RESUMO

Alzheimer disease (AD) accounts for 60-70% of dementia cases. Given the seriousness of the disease and continual increase in patient numbers, developing effective therapies to treat AD has become urgent. Presently, the drugs available for AD treatment, including cholinesterase inhibitors and an antagonist of the N-methyl-D-aspartate receptor, can only inhibit dementia symptoms for a limited period of time but cannot stop or reverse disease progression. On the basis of the amyloid hypothesis, many global drug companies have conducted many clinical trials on amyloid clearing therapy but without success. Thus, the amyloid hypothesis may not be completely feasible. The number of anti-amyloid trials decreased in 2019, which might be a turning point. An in-depth and comprehensive understanding of the contribution of amyloid beta and other factors of AD is crucial for developing novel pharmacotherapies.In ongoing clinical trials, researchers have developed and are testing several possible interventions aimed at various targets, including anti-amyloid and anti-tau interventions, neurotransmitter modification, anti-neuroinflammation and neuroprotection interventions, and cognitive enhancement, and interventions to relieve behavioral psychological symptoms. In this article, we present the current state of clinical trials for AD at clinicaltrials.gov. We reviewed the underlying mechanisms of these trials, tried to understand the reason why prior clinical trials failed, and analyzed the future trend of AD clinical trials.


Assuntos
Doença de Alzheimer/tratamento farmacológico , Inibidores da Colinesterase/uso terapêutico , Receptores de N-Metil-D-Aspartato/antagonistas & inibidores , Doença de Alzheimer/metabolismo , Doença de Alzheimer/patologia , Peptídeos beta-Amiloides , Ensaios Clínicos como Assunto , Humanos
11.
Nat Rev Gastroenterol Hepatol ; 17(1): 21-39, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31690829

RESUMO

Functional constipation is common in children and adults worldwide. Functional constipation shows similarities in children and adults, but important differences also exist regarding epidemiology, symptomatology, pathophysiology, diagnostic workup and therapeutic management. In children, the approach focuses on the behavioural nature of the disorder and the initial therapeutic steps involve toilet training and laxatives. In adults, management focuses on excluding an underlying cause and differentiating between different subtypes of functional constipation - normal transit, slow transit or an evacuation disorder - which has important therapeutic consequences. Treatment of adult functional constipation involves lifestyle interventions, pelvic floor interventions (in the presence of a rectal evacuation disorder) and pharmacological therapy. When conventional treatments fail, children and adults are considered to have intractable functional constipation, a troublesome and distressing condition. Intractable constipation is managed with a stepwise approach and in rare cases requires surgical interventions such as antegrade continence enemas in children or colectomy procedures for adults. New drugs, including prokinetic and prosecretory agents, and surgical strategies, such as sacral nerve stimulation, have the potential to improve the management of children and adults with intractable functional constipation.


Assuntos
Constipação Intestinal/terapia , Fármacos Gastrointestinais/uso terapêutico , Laxantes/uso terapêutico , Agonistas do Receptor 5-HT4 de Serotonina/uso terapêutico , Adulto , Ácidos e Sais Biliares/uso terapêutico , Biorretroalimentação Psicológica , Criança , Agonistas dos Canais de Cloreto/uso terapêutico , Inibidores da Colinesterase/uso terapêutico , Constipação Intestinal/diagnóstico , Constipação Intestinal/fisiopatologia , Dietoterapia , Fibras na Dieta , Gerenciamento Clínico , Terapia por Estimulação Elétrica , Enema , Microbioma Gastrointestinal , Trânsito Gastrointestinal , Agonistas da Guanilil Ciclase C/uso terapêutico , Humanos , Manometria , Educação de Pacientes como Assunto , Prebióticos , Probióticos , Treinamento no Uso de Toaletes
12.
BMJ Case Rep ; 12(12)2019 Dec 08.
Artigo em Inglês | MEDLINE | ID: mdl-31818887

RESUMO

A 24-year-old otherwise healthy male presented to us with unilateral ptosis and contralateral lid retraction with limitation of extraocular movements; the disease had a gradual chronic course, which raised a suspicion of ocular myasthenia. Ice pack test was performed, which improved the ptosis; further investigations confirmed the diagnosis of ocular myasthenia. Patient was started on pyridostigmine and oral prednisolone which improved the extraocular movements and ptosis.


Assuntos
Técnicas de Diagnóstico Oftalmológico , Oftalmopatias/diagnóstico , Miastenia Gravis/diagnóstico , Blefaroptose/etiologia , Inibidores da Colinesterase/uso terapêutico , Temperatura Baixa , Diagnóstico Diferencial , Oftalmopatias/tratamento farmacológico , Movimentos Oculares , Seguimentos , Glucocorticoides/uso terapêutico , Humanos , Masculino , Miastenia Gravis/tratamento farmacológico , Prednisolona/uso terapêutico , Brometo de Piridostigmina/uso terapêutico , Resultado do Tratamento , Adulto Jovem
13.
BMJ ; 367: l6217, 2019 12 06.
Artigo em Inglês | MEDLINE | ID: mdl-31810978

RESUMO

Alzheimer's disease (AD) is a progressive neurodegenerative disease characterized by the accumulation of amyloid ß in the form of extracellular plaques and by intracellular neurofibrillary tangles, with eventual neurodegeneration and dementia. There is currently no disease-modifying treatment though several symptomatic medications exist with modest benefit on cognition. Acetylcholinesterase inhibitors have a consistent benefit across all stages of dementia; their benefit in mild cognitive impairment and prodromal AD is unproven. Memantine has a smaller benefit on cognition overall which is limited to the moderate to severe stages, and the combination of a cholinesterase inhibitor and memantine may have additional efficacy. Evidence for the efficacy of vitamin E supplementation and medical foods is weak but might be considered in the context of cost, availability, and safety in individual patients. Apparently promising disease-modifying interventions, mostly addressing the amyloid cascade hypothesis of AD, have recently failed to demonstrate efficacy so novel approaches must be considered.


Assuntos
Doença de Alzheimer/tratamento farmacológico , Doença de Alzheimer/psicologia , Peptídeos beta-Amiloides/farmacologia , Peptídeos beta-Amiloides/uso terapêutico , Inibidores da Colinesterase/farmacologia , Inibidores da Colinesterase/uso terapêutico , Doença de Alzheimer/fisiopatologia , Doença de Alzheimer/prevenção & controle , Preparações de Ação Retardada , Quimioterapia Combinada , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
14.
Zh Nevrol Psikhiatr Im S S Korsakova ; 119(9. Vyp. 2): 56-59, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31825391

RESUMO

Donepezil is the most commonly used cholinesterase inhibitor. The indication for its use is Alzheimer's disease. A number of clinical studies have shown its effectiveness in vascular dementia, dementia with Lewy bodies, Parkinson's disease with dementia, dementia due to traumatic brain injury. It is shown that dementia is a risk factor for falls, and standard measures to prevent falls in the elderly are ineffective in patients with cognitive impairment. This article provides a review of publications on the influence of donepezil on gait and balance. Most authors agree that donepezil is able to improve some parameters of gait, such as gait velocity and stride time variability, which can increase stability and reduce the risk of falls. The effect of donepezil on motor function is small, but its use may be particularly valuable if other approaches to treatment of gait disorders in patients with cognitive impairment are ineffective.


Assuntos
Inibidores da Colinesterase , Demência , Donepezila , Transtornos Neurológicos da Marcha , Indanos , Idoso , Inibidores da Colinesterase/uso terapêutico , Demência/complicações , Donepezila/uso terapêutico , Marcha , Transtornos Neurológicos da Marcha/tratamento farmacológico , Transtornos Neurológicos da Marcha/etiologia , Humanos , Piperidinas
15.
Clin Interv Aging ; 14: 2071-2083, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31819389

RESUMO

Introduction: Despite recommendations from associations of geriatric and psychiatry societies and warnings from drug agencies, antipsychotic (AP) drugs are frequently used to control behavioral and psychological symptoms of dementia. APs are associated with a range of potential adverse events, including increased risk of cerebrovascular events and mortality. Evidence suggests limited efficacy of APs for aggression and psychosis. Our objectives were to investigate patterns and predictors for prescription of APs among older adults with dementia residing in a large region of central Italy, and to identify patient characteristics related to typical or atypical APs prescribing. Methods: This is a retrospective population-based cohort study using data from regional health information systems (HIS). We included dementia patients aged ≥65 years residing in the Lazio region. The exposure was defined as new use vs non-use of APs. Dementia patients with incident use of APs during 2015 were followed-up from the date of first prescription to the earliest among discontinuation of use, death, or end of study (December 31, 2016). Results: We enrolled 24,735 dementia patients, 1727 (6.7%) new users and 23,008 non-users of APs. Forty-four percent of AP users were treated for more than 3 months, and among these about 60% received APs continuously for at least 12 months. Individuals using antidepressant or anti-dementia drugs had higher odds of being prescribed with APs (OR: 1.67 and OR: 1.86, respectively). Patients exposed to polypharmacy were less likely to receive APs (OR: 0.82). Cardiovascular risk factors and comorbidities were not associated with APs use. Low socio-economic position was associated with lower odds of atypical AP prescribing (OR: 0.57). Conclusion: The study showed that a not negligible proportion of patients had a period of AP use longer than recommended by guidelines. We identified socio-demographic and clinical factors associated with first use of APs, providing insight into prescribing practices in a community setting and useful information to address areas of potential inappropriateness.


Assuntos
Antipsicóticos/administração & dosagem , Demência/tratamento farmacológico , Vida Independente , Idoso , Idoso de 80 Anos ou mais , Antidepressivos , Antipsicóticos/efeitos adversos , Inibidores da Colinesterase/uso terapêutico , Bases de Dados Factuais , Demência/psicologia , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Sistemas de Informação em Saúde , Hospitalização/estatística & dados numéricos , Humanos , Itália , Estudos Longitudinais , Masculino , Estudos Retrospectivos
16.
J Clin Psychiatry ; 80(6)2019 12 03.
Artigo em Inglês | MEDLINE | ID: mdl-31846243

RESUMO

​​​​Effective multifactorial management of Alzheimer's disease (AD) requires a triadic alliance of the clinician, the patient, and the patient's family and/or care partner(s). During the evaluation process and when the diagnosis of AD is delivered, these parties must work together to set goals and develop care plans. Care plans should be designed to help the patient maintain safety and autonomy as long as he or she can and, once autonomy is no longer possible, to allow the patient and care partner(s) to experience as much comfort and the best possible quality of life for as long as possible. In this Academic Highlights, faculty members from neurology, psychiatry, neuropsychology, and primary care share their recommendations, supported by current evidence and guidelines, for handling the complexities of providing care for patients with AD.


Assuntos
Doença de Alzheimer/terapia , Adaptação Psicológica , Idoso , Doença de Alzheimer/psicologia , Cuidadores/educação , Cuidadores/psicologia , Inibidores da Colinesterase/uso terapêutico , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/psicologia , Transtornos Cognitivos/terapia , Terapia Combinada , Efeitos Psicossociais da Doença , Feminino , Humanos , Comportamento de Doença , Estilo de Vida , Masculino , Memantina/uso terapêutico , Pessoa de Meia-Idade , Planejamento de Assistência ao Paciente , Equipe de Assistência ao Paciente , Educação de Pacientes como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto
17.
Medicine (Baltimore) ; 98(52): e18406, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31876713

RESUMO

As an anesthetic reversal agent, there are concerns with cholinesterase inhibitors regarding worsening of Parkinson's disease (PD)-related symptoms. Sugammadex, a relatively new reversal agent, does not inhibit acetylcholinesterase and does not require co-administration of an antimuscarinic agent. The present study compared the recovery profiles of 2 agents initially administered for reversal of neuromuscular blockade in patients with advanced PD who underwent deep brain stimulator implantation.A total of 121 patients with PD who underwent deep brain stimulator implantation were retrospectively analyzed. Patients were divided into 1 of 2 groups according to the type of neuromuscular blockade reversal agent (pyridostigmine vs sugammadex) initially administered. Recovery profiles reflecting time to extubation, reversal failure at first attempt, and hemodynamic stability, including incidence of hypertension or tachycardia during the emergence period, were compared.Time to extubation in the sugammadex group was significantly shorter (P < .001). In the sugammadex group, reversal failure at first attempt did not occur in any patient, while it occurred in seven (9.7%) patients in the pyridostigmine group (P = .064), necessitating an additional dose of pyridostigmine (n = 3) or sugammadex (n = 4). The incidence of hemodynamic instability during anesthetic emergence was significantly lower in the sugammadex group than in the pyridostigmine group (P = .019).Sugammadex yielded a recovery profile superior to that of pyridostigmine during the anesthesia emergence period in advanced PD patients. Sugammadex is also likely to be associated with fewer adverse effects than traditional reversal agents, which in turn would also improve overall postoperative management in this patient population.


Assuntos
Inibidores da Colinesterase/uso terapêutico , Estimulação Encefálica Profunda , Eletrodos Implantados , Bloqueio Neuromuscular/métodos , Doença de Parkinson/terapia , Implantação de Prótese , Brometo de Piridostigmina/uso terapêutico , Sugammadex/uso terapêutico , Período de Recuperação da Anestesia , Estimulação Encefálica Profunda/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Neuromuscular/efeitos adversos , Implantação de Prótese/métodos , Estudos Retrospectivos
18.
Handb Clin Neurol ; 165: 253-267, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31727216

RESUMO

The pathophysiology of traumatic brain injury (TBI) can be highly variable, involving functional and/or structural damage to multiple neuroanatomical networks and neurotransmitter systems. This wide-ranging potential for physiologic injury is reflected in the diversity of neurobehavioral and neurocognitive symptoms following TBI. Here, we aim to provide a succinct, clinically relevant, up-to-date review on psychopharmacology for the most common sequelae of TBI in the postacute to chronic period. Specifically, treatment for neurobehavioral symptoms (depression, mania, anxiety, agitation/irritability, psychosis, pseudobulbar affect, and apathy) and neurocognitive symptoms (processing speed, attention, memory, executive dysfunction) will be discussed. Treatment recommendations will reflect general clinical practice patterns and the research literature.


Assuntos
Lesões Encefálicas Traumáticas/tratamento farmacológico , Lesões Encefálicas Traumáticas/psicologia , Transtornos Cognitivos/tratamento farmacológico , Transtornos Cognitivos/psicologia , Transtornos Mentais/tratamento farmacológico , Transtornos Mentais/psicologia , Antioxidantes/uso terapêutico , Lesões Encefálicas Traumáticas/complicações , Inibidores da Colinesterase/uso terapêutico , Transtornos Cognitivos/etiologia , Humanos , Transtornos Mentais/etiologia , Psicofarmacologia
19.
JAMA ; 322(16): 1589-1599, 2019 10 22.
Artigo em Inglês | MEDLINE | ID: mdl-31638686

RESUMO

Importance: Worldwide, 47 million people live with dementia and, by 2050, the number is expected to increase to 131 million. Observations: Dementia is an acquired loss of cognition in multiple cognitive domains sufficiently severe to affect social or occupational function. In the United States, Alzheimer disease, one cause of dementia, affects 5.8 million people. Dementia is commonly associated with more than 1 neuropathology, usually Alzheimer disease with cerebrovascular pathology. Diagnosing dementia requires a history evaluating for cognitive decline and impairment in daily activities, with corroboration from a close friend or family member, in addition to a thorough mental status examination by a clinician to delineate impairments in memory, language, attention, visuospatial cognition such as spatial orientation, executive function, and mood. Brief cognitive impairment screening questionnaires can assist in initiating and organizing the cognitive assessment. However, if the assessment is inconclusive (eg, symptoms present, but normal examination findings), neuropsychological testing can help determine whether dementia is present. Physical examination may help identify the etiology of dementia. For example, focal neurologic abnormalities suggest stroke. Brain neuroimaging may demonstrate structural changes including, but not limited to, focal atrophy, infarcts, and tumor, that may not be identified on physical examination. Additional evaluation with cerebrospinal fluid assays or genetic testing may be considered in atypical dementia cases, such as age of onset younger than 65 years, rapid symptom onset, and/or impairment in multiple cognitive domains but not episodic memory. For treatment, patients may benefit from nonpharmacologic approaches, including cognitively engaging activities such as reading, physical exercise such as walking, and socialization such as family gatherings. Pharmacologic approaches can provide modest symptomatic relief. For Alzheimer disease, this includes an acetylcholinesterase inhibitor such as donepezil for mild to severe dementia, and memantine (used alone or as an add-on therapy) for moderate to severe dementia. Rivastigmine can be used to treat symptomatic Parkinson disease dementia. Conclusions and Relevance: Alzheimer disease currently affects 5.8 million persons in the United States and is a common cause of dementia, which is usually accompanied by other neuropathology, often cerebrovascular disease such as brain infarcts. Causes of dementia can be diagnosed by medical history, cognitive and physical examination, laboratory testing, and brain imaging. Management should include both nonpharmacologic and pharmacologic approaches, although efficacy of available treatments remains limited.


Assuntos
Demência/diagnóstico , Demência/terapia , Doença de Alzheimer/diagnóstico , Doença de Alzheimer/terapia , Inibidores da Colinesterase/efeitos adversos , Inibidores da Colinesterase/uso terapêutico , Antagonistas de Aminoácidos Excitatórios/efeitos adversos , Antagonistas de Aminoácidos Excitatórios/uso terapêutico , Humanos , Memantina/efeitos adversos , Memantina/uso terapêutico , Neuroimagem , Testes Neuropsicológicos
20.
Medicina (B Aires) ; 79 Suppl 3: 71-76, 2019.
Artigo em Espanhol | MEDLINE | ID: mdl-31603848

RESUMO

Juvenile myasthenia gravis is a rare autoimmune disease, which has made it difficult to collect data from prospective randomized controlled trials to evaluate the efficacy and results of different treatments. Although there are differences between the juvenile myasthenia gravis and that of the adult, the data provided by some researches in adults in the treatment of juvenile myasthenia gravis have been used. The different therapeutic options will be evaluated, with the different evidences that sustain it and a treatment algorithm will be elaborated keeping always in mind that each patient offers us different challenges.


Assuntos
Miastenia Gravis/terapia , Criança , Inibidores da Colinesterase/uso terapêutico , Humanos , Imunossupressores/classificação , Imunossupressores/uso terapêutico , Miastenia Gravis/cirurgia , Esteroides/uso terapêutico , Timectomia
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