Superior oblique myokymia: efficacy of medical treatment.

PURPOSE: Superior oblique myokymia (SOM) is an uncommon disorder characterized by episodic monocular oscillopsia. Several medications have been reported to be of benefit for some patients with this condition, but the efficacy of medical treatment has not been well established and little long-term follow-up data are available. The purpose of this study was to better clarify the role of medical therapy in the management of SOM. METHODS: A retrospective review of patients with this disorder seen in an outpatient neuro-ophthalmology clinic. The diagnosis of SOM was based on a history of episodic unilateral oscillopsia with or without torsional diplopia. Twenty-seven patients with SOM were identified. Twenty of these were treated medically and these formed the basis of the study. Follow-up interval ranged from 1 to 12.5 years (mean, 6.5 years). The main outcome measure was relief of oscillopsia. RESULTS: Fifteen of the 18 patients treated with carbamazepine (83%) reported some benefit, 6 of whom continue to do well on medication 9 months to 5 years later. In four patients improvement was only transient and in five others treatment was subsequently discontinued for various reasons. In addition, one patient had sustained benefit from phenytoin, one from propranolol, and one from propranolol plus valproic acid. We found no treatment success with baclofen. Overall, nine patients (45%) enjoy sustained benefit unassociated with adverse side effects. CONCLUSIONS: In contrast to previous reports emphasizing the efficacy of surgery for SOM, our data demonstrate the potential benefits of medical treatment for patients with this disorder.

Cognitive behavioural therapy for obesity and binge eating associated to antipsychotic drugs

Background and Aims: Overweight, obesity and binge eating disorder are commonly reported in persons with severe mental disorders. Particularly, antipsychotic drugs (AP) induce weight gain in up to half of the patients. The aim of the present study is to confirm a previous study results on a larger sample of patients, to assess the impact of the interventions on other relevant dimensions of eating and weight related cognitions as well as to assess potential clinical indicators of outcomes such as AP drug, concomitant treatment with lithium or carbamazepine, psychiatric diagnostic, binge eating and severity of cognitive distortions. Method: A controlled study (12-week CBT vs. B N E) was carried out on 99 patients treated with an AP and who have gained weight following this treatment. Binge eating symptomatology, eating and weight-related cognitions, as well as weight and body mass index were assessed before treatment, at 12 weeks and at 24 weeks. Results: The findings confirms usefulness and effectiveness of the proposed CBT program on the treatment of binge symptomatology, cognitive distortions and obesity in patients treated with AP. Reduction of binge symptoms and maladapted cognitions appeared early, whereas the effect on weight appeared later during the follow up observation. No differences on outcomes were found across pharmacotherapy characteristics, diagnostic categories, binge eating nor severity of cognitive distortions. Conclusion: The proposed CBT treatment is useful for patients suffering from weight gain associated with AP treatments indeed when a concomitant treatment with lithium or valproate was given.

Anticonvulsants in the treatment of aggression in the demented elderly: an update

Complex psychopathological and behavioral symptoms, such as delusions and aggression against care providers, are often the primary cause of acute hospital admissions of elderly patients to emergency units and psychiatric departments. This issue resembles an interdisciplinary clinically highly relevant diagnostic and therapeutic challenge across many medical subjects and general practice. At least 50% of the dramatically growing number of patients with dementia exerts aggressive and agitated symptoms during the course of clinical progression, particularly at moderate clinical severity. METHODS: Commonly used rating scales for agitation and aggression are reviewed and discussed. Furthermore, we focus in this article on benefits and limitations of all available data of anticonvulsants published in this specific indication, such as valproate, carbamazepine, oxcarbazepine, lamotrigine, gabapentin and topiramate. RESULTS: To date, most positive and robust data are available for carbamazepine, however, pharmacokinetic interactions with secondary enzyme induction limit its use. Controlled data of valproate do not seem to support the use in this population. For oxcarbazepine only one controlled but negative trial is available. Positive small series and case reports have been reported for lamotrigine, gabapentin and topiramate. CONCLUSION: So far, data of anticonvulsants in demented patients with behavioral disturbances are not convincing. Controlled clinical trials using specific, valid and psychometrically sound instruments of newer anticonvulsants with a better tolerability profile are mandatory to verify whether they can contribute as treatment option in this indication.

Anticonvulsants in the treatment of aggression in the demented elderly: an update

Complex psychopathological and behavioral symptoms, such as delusions and aggression against care providers, are often the primary cause of acute hospital admissions of elderly patients to emergency units and psychiatric departments. This issue resembles an interdisciplinary clinically highly relevant diagnostic and therapeutic challenge across many medical subjects and general practice. At least 50% of the dramatically growing number of patients with dementia exerts aggressive and agitated symptoms during the course of clinical progression, particularly at moderate clinical severity. METHODS: Commonly used rating scales for agitation and aggression are reviewed and discussed. Furthermore, we focus in this article on benefits and limitations of all available data of anticonvulsants published in this specific indication, such as valproate, carbamazepine, oxcarbazepine, lamotrigine, gabapentin and topiramate. RESULTS: To date, most positive and robust data are available for carbamazepine, however, pharmacokinetic interactions with secondary enzyme induction limit its use. Controlled data of valproate do not seem to support the use in this population. For oxcarbazepine only one controlled but negative trial is available. Positive small series and case reports have been reported for lamotrigine, gabapentin and topiramate. CONCLUSION: So far, data of anticonvulsants in demented patients with behavioral disturbances are not convincing. Controlled clinical trials using specific, valid and psychometrically sound instruments of newer anticonvulsants with a better tolerability profile are mandatory to verify whether they can contribute as treatment option in this indication.

Jumping Jack Flash.

A 38-year-old woman presented with blurred vision and "jumping" of the right eye for 7 months. Magnetic resonance imaging of the head was normal. Intermittent intorsion of the right eye was noted on examination, consistent with superior oblique myokymia. She was initially treated with carbamazepine but stopped after becoming light-headed. The diagnosis and treatment of superior oblique myokymia are discussed.

Towards desired crystalline product properties: In-situ monitoring of batch crystallization

The objective of industrial crystallization is to obtain a crystalline product which has the desired crystal size distribution, mean crystal size, crystal shape, purity, polymorphic and pseudopolymorphic form. Effective control of the product quality requires an understanding of the thermodynamics of the crystallizing system and the effects of operation parameters on the crystalline product properties. Therefore, obtaining reliable in-line information about crystal properties and supersaturation, which is the driving force of crystallization, would be very advantageous. Advanced techniques, such asRaman spectroscopy, attenuated total reflection Fourier transform infrared (ATR FTIR) spectroscopy, and in-line imaging techniques, offer great potential for obtaining reliable information during crystallization, and thus giving a better understanding of the fundamental mechanisms (nucleation and crystal growth) involved. In the present work, the relative stability of anhydrate and dihydrate carbamazepine in mixed solvents containing water and ethanol were investigated. The kinetics of the solvent mediated phase transformation of the anhydrate to hydrate in the mixed solvents was studied using an in-line Raman immersion probe. The effects of the operation parameters in terms of solvent composition, temperature and the use of certain additives on the phase transformation kineticswere explored. Comparison of the off-line measured solute concentration and the solid-phase composition measured by in-line Raman spectroscopy allowedthe identification of the fundamental processes during the phase transformation. The effects of thermodynamic and kinetic factors on the anhydrate/hydrate phase of carbamazepine crystals during cooling crystallization were also investigated. The effect of certain additives on the batch cooling crystallization of potassium dihydrogen phosphate (KDP) wasinvestigated. The crystal growth rate of a certain crystal face was determined from images taken with an in-line video microscope. An in-line image processing method was developed to characterize the size and shape of thecrystals. An ATR FTIR and a laser reflection particle size analyzer were used to study the effects of cooling modes and seeding parameters onthe final crystal size distribution of an organic compound C15. Based on the obtained results, an operation condition was proposed which gives improved product property in terms of increased mean crystal size and narrowersize distribution.

Age and adverse drug reactions from psychopharmacological treatment: data from the AMSP drug surveillance programme in Switzerland.

QUESTION UNDER STUDY: The frequency of severe adverse drug reactions (ADRs) from psychotropic drugs was investigated in hospitalised psychiatric patients in relation to their age. Specifically, the incidence of ADRs in patients up to 60 years was compared to that of patients older than 60 years. METHODS: Prescription rates of psychotropic drugs and reports of severe ADRs were collected in psychiatric hospitals in Switzerland between 2001 and 2010. The data stem from the drug surveillance programme AMSP. RESULTS: A total of 699 patients exhibited severe ADRs: 517 out of 28,282 patients up to 60 years (1.8%); 182 out of 11,446 elderly patients (1.6%, ns). Logistic regression analyses showed a significantly negative relationship between the incidence of ADRs and patients' age in general and in particular for weight gain, extrapyramidal motor system (EPMS) symptoms, increased liver enzymes and galactorrhoea. A significantly negative relationship was observed for age and the dosages of olanzapine, quetiapine, risperidone, valproic acid and lamotrigine. When comparing age groups, frequency of ADRs was lower in general for antipsychotic drugs and anticonvulsants, in particular for valproic acid in the elderly. Weight gain was found to be lower in the elderly for antipsychotic drugs, in particular for olanzapine. For the group of mood-stabilising anticonvulsants (carbamazepine, lamotrigine and valproic acid) the elderly exhibited a lower incidence of reported allergic skin reactions. CONCLUSION: The results suggest that for psychiatric inpatients the incidence of common severe ADRs (e.g., weight gain or EPMS symptoms) arising from psychotropic medication decreases with the age of patients.

Validação de modelos de calibração multivariada: uma aplicação na determinação de pureza polimórfica de carbamazepina por espectroscopia no infravermelho próximo

The application of analytical procedures based on multivariate calibration models has been limited in several areas due to requirements of validation and certification of the model. Procedures for validation are presented based on the determination of figures of merit, such as precision (mean, repeatability, intermediate), accuracy, sensitivity, analytical sensitivity, selectivity, signal-to-noise ratio and confidence intervals for PLS models. An example is discussed of a model for polymorphic purity control of carbamazepine by NIR diffuse reflectance spectroscopy. The results show that multivariate calibration models can be validated to fulfill the requirements imposed by industry and standardization agencies.

High performance thin layer chromatographic determination of nifedipine in human serum after liquid-liquid extraction

A method using HPTLC for quantitation of nifedipine in serum was developed and validated. It includes a liquid-liquid extraction, and carbamazepine as internal standard. Chloroform: ethyl acetate: cyclohexane (19:2:2, v/v/v) was the mobile phase. The method showed good relationship (r = 0.996) (2.00 to 25.00 ng/band, corresponding to 0.02 and 0.25 ng/µL in serum). The % RSD of intra-assay and inter-assay, were between 0.57 and 3.56 and 1.16 to 3.60, respectively. LOD and LOQ were 0.72 and 0.86 ng/band, respectively. The recovery values were between 93 and 102%. Rf for nifedipine and carbamazepine were 0.31 and 0.10, respectively.

Determinação simultânea de topiramato, carbamazepina, fenitoína e fenobarbital em plasma empregando cromatografia a gás com detector de nitrogênio e fósforo

Topiramate and the other frequently co-administered antiepileptic drugs carbamazepine, phenytoin and phenobarbital were determined in 100 µL plasma samples by gas chromatography with nitrogen phosphorus detection (GC-NPD), after a one-step liquid-liquid extraction with ethyl acetate, followed by flash methylation with trimethylphenylammonium hydroxide. Total chromatographic run time was 12.5 min. Intra-assay and inter-assay precision was 2.5-7.3% and 1.6-5.2%, respectively. Accuracy was 100.1-104.2%. The limit of quantitation was 1 µg mL-1 for all analytes, proving suitable for routine application in therapeutic drug monitoring of antiepileptic drugs.

A influência da piperina na biodisponibilidade de fármacos: uma abordagem molecular

Piperine is the major alkaloid of Piper nigrum Linn., used as a spice and in folk medicine. We present a molecular docking study supporting experimental data on the enhancement in bioavailability of propranolol, theophylline, phenytoin, nevirapine, nimesulide, pyrazinamide, carbamazepine, and spartein in the presence of piperine. The complex formed with piperine and CYP3A4 was shown to be the most stable of all, with a binding energy of -8.60 kcal/mol. This explains the related mechanism of drug-herb interaction, since the better anchoring of piperine in the active site of CYP3A4 can hinder the drug-enzyme interaction, thereby increasing the bioavailability of the drugs studied.

Análise de fármacos em águas por SPE-UPLC-ESI-MS/MS

A method was developed for the analysis of 31 pharmaceutical compounds in Lisbon's drinking water system, using solid-phase extraction (SPE) and ultra-performance liquid chromatography coupled to tandem mass spectrometry (UPLC-MS/MS). The method was validated through estimation of the linearity range, method detection and quantification limits, matrix effects, precision and accuracy. The method detection and quantification limit ranges were 0.009-10 and 0.03-33 ng/L, respectively. Analytes were quantified in water samples collected from the EPAL (Empresa Portuguesa das Águas Livres S.A.) supply system. Carbamazepine, atenolol, sulfadiazine, sulfamethazine, sulfapyridine, sulfamethoxazole, acetaminophen, caffeine and erythromycin were quantified in the analysed samples.

Determinação simultânea de carbamazepina, fenitoína e fenobarbital em sangue seco em papel por cromatografia líquida de alta eficiência

Carbamazepine, phenobarbital and phenytoin were determined in dried blood spots (DBS) by high performance liquid chromatography, after extraction of 8 mm DBS using a mixture of acetonitrile and methanol. Analytes were separated by reversed-phase chromatography, with a run time of 17 minutes. Intra-assay and inter-assay precisions were in the 5.3 to 8.4% and 3.3 to 5.2% ranges, respectively. Accuracy was in the 98.8 to 104.3% range. The method had sensitivity to detect all analytes at levels below minimum therapeutic concentrations. The analytes were stable at 4 ºC and room temperature for up to 12 days and at 45 ºC for 9 days. The method was applied to 14 paired clinical samples of blood serum and DBS.

Karbamatsepiinin Haihdutuskiteytys

Haihdutuskiteytyksessä haihdutusolosuhteilla on suuri vaikutus kiteiden muodostumiseen, joten toivottujen kidemuotojen saamiseksi prosessia on hallittava tarkasti. Kandidaatintyön tavoitteena oli tutkia puhtaiden liuottimien ja karbamatsepiiniliuosten haihtumisvuota eri olosuhteissa. Lisäksi tutkittiin kiteytysolosuhteiden vaikutusta karbamatsepiinikiteiden muodostumiseen ja rakenteeseen. Puhtaille liuottimille kokeet suoritettiin ilman virtausnopeudella 0,2 m/s lämpötiloissa 30 ºC, 40 ºC, 50 ºC ja 60 ºC, sekä ilman virtausnopeudella 0,3 m/s lämpötiloissa 40 ºC ja 50 ºC. Karbamatsepiiniliuoksille kokeet suoritettiin ilman virtausnopeudella 0,2 m/s lämpötiloissa 30 ºC ja 60 ºC sekä ilman virtausnopeudella 0,3 m/s lämpötiloissa 40 ºC ja 50 ºC. Haihdutuskiteytys suoritettiin suorakulmaisessa haihdutuskammiossa, jonka toisessa päässä oli tuulettimet virtausnopeuden säätämiseksi. Koehuoneessa vallitsi normaali ilmanpaine, ilman suhteellinen kosteus vaihteli välillä 50–65 % ja huoneen lämpötila välillä 21,2–24,1 ºC. Kuivatut kiteet analysoitiin optisella mikroskoopilla. Kaikista karbamatsepiinin vesiliuoksista kiteytyi dihydraatti-muotoa. Muutokset haihdutusolosuhteissa vaikuttivat selvästi haihtumis-voihin ja muodostuvien kiteiden rakenteeseen.

An HPLC-UV method for the measurement of permeability of marker drugs in the Caco-2 cell assay

The Caco-2 cell line has been used as a model to predict the in vitro permeability of the human intestinal barrier. The predictive potential of the assay relies on an appropriate in-house validation of the method. The objective of the present study was to develop a single HPLC-UV method for the identification and quantitation of marker drugs and to determine the suitability of the Caco-2 cell permeability assay. A simple chromatographic method was developed for the simultaneous determination of both passively (propranolol, carbamazepine, acyclovir, and hydrochlorothiazide) and actively transported drugs (vinblastine and verapamil). Separation was achieved on a C18 column with step-gradient elution (acetonitrile and aqueous solution of ammonium acetate, pH 3.0) at a flow rate of 1.0 mL/min and UV detection at 275 nm during the total run time of 35 min. The method was validated and found to be specific, linear, precise, and accurate. This chromatographic system can be readily used on a routine basis and its utilization can be extended to other permeability models. The results obtained in the Caco-2 bi-directional transport experiments confirmed the validity of the assay, given that high and low permeability profiles were identified, and P-glycoprotein functionality was established.