Clinical Neuropharmacology最新文献

Background: While there is still debate over the benefit of antipsychotics in delirium management, surveys indicate their frequent use in clinical practice. Previous systematic reviews and meta-analyses have focused on assessing the effectiveness of antipsychotics versus placebo in delirium management. However, despite increasing access to atypical antipsychotics in hospital settings, robust analyses of studies comparing the effectiveness of haloperidol and atypical antipsychotics are lacking.

Objectives: To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the effectiveness and safety of haloperidol versus atypical antipsychotics in the management of delirium patients.

Methods: We conducted a systematic search of Medline, Scopus, and Cochrane for RCTs comparing atypical antipsychotics with haloperidol in delirium patients. Odds ratio (OR) was used to analyze dichotomous variables. Continuous outcomes were compared using mean difference (MD) and standardized mean difference (SMD). The random effects model was applied to all endpoints.

Results: Eleven RCTs (n=1450 patients) met the eligibility criteria. Delirium severity (SMD, -0.03; [95% CI, -0.20 to 0.15]; P = 0.78) and overall mortality (OR, 1.26; [95% CI, 0.88-1.80]; P = 0.20) did not differ significantly between groups. However, patients treated with haloperidol had significantly higher odds of experiencing extrapyramidal symptoms compared with those treated with atypical antipsychotics (OR, 2.72; [95% CI, 1.26-5.87]; P = 0.01).

Conclusions: While there were no significant differences in the effectiveness between treatments, patients treated with haloperidol had nearly a 3-fold increase in the incidence of extrapyramidal symptoms, indicating a potential advantage of atypical antipsychotics in minimizing adverse effects.

Objectives: Catatonia is a neuropsychiatric syndrome with diverse etiologies, often presenting significant diagnostic and research challenges due to an extremely heterogenic symptomology and pathology. The differential for catatonia is further complicated by distinct, non-catatonic medical mimics of catatonia that present similarly. We propose a new delineation of medical mimics of catatonia and an approach to differential diagnosis that will better account for the complexities of catatonia and its mimics, ultimately leading to more clinically relevant outcomes.

Methods: We obtained all case reports and case series from a Regional Medical Center in a 6-month period. All patients were diagnosed initially with F06.1 Catatonia. All patients had assessments with Bush-Francis Catatonia Rating Scale and the KANNER catatonia rating scale. Data included diagnoses, comorbidities, treatment approaches, and outcomes.

Results: We found 12 cases that met the inclusion criteria. We identified the primary diagnosis of catatonia and comorbid diagnoses. There were 3 case studies, 4 case series (N=2), and 1 presentation. Six of the 12 had co-existing medical conditions that are classified as medical mimics of catatonia. The treatment approach, diagnostic workup, and outcomes were available for all cases.

Conclusions: Our finding of 50% medical mimics in our study of catatonia is analogous to encountering Viceroys in the Butterfly Garden with the Monarchs. The medical mimics, the Viceroys, are often excluded from the study of catatonia, the Monarchs, and reduce the study population. Nonetheless, the Viceroys encountered on psychiatric units, outpatient clinics, emergency rooms and consultation-liaison services still warrant assessment and treatment.

Objectives: Bálint syndrome is a debilitating, rare neurological condition characterized by a triad of visuospatial distortions: simultanagnosia, optic ataxia, and oculomotor apraxia. We highlight the pathways involved with infarction of the posterior cerebral artery (PCA), which may be an important underlying factor leading to the development of clinical presentations found in Bálint syndrome.

Methods: We present a case of a middle-aged patient who presents with Bálint syndrome following a PCA infarction.

Results: A 49-year-old male bus driver with a recent PCA infarction presented with all 3 components of Bálint syndrome. His clinical course was notable for simultanagnosia, optic ataxia, oculomotor apraxia, and a right greater than left lower visual field deficit. Neuroimaging revealed infarctions in the P1 and bilateral P2 segments of the posterior cerebral arteries, affecting the parieto-occipital regions known to underlie visuospatial processing. Laboratory workup helped exclude opportunistic and systemic causes, supporting a stroke-related etiology.

Conclusions: Posterior cerebral artery infarctions may be responsible for the clinical presentation of Bálint syndrome; however, further investigation into vascular and neuronal networks underlying the clinical signs and symptoms of Bálint syndrome is needed.

Objective: Electroconvulsive therapy (ECT) is an effective treatment for severe psychiatric disorders but is frequently associated with cognitive side effects. This study aimed to evaluate the effects of rivastigmine and memantine on cognitive function following ECT.

Methods: In this multicenter, randomized, double-blind, placebo-controlled trial (registration number: IRCT20190119042417N2), 45 patients receiving ECT were allocated equally to rivastigmine, memantine, or placebo groups. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) at baseline, week 2, and week 6. Individual slopes of MoCA change over time were computed using simple linear regression, and group-level comparisons were conducted using t tests and adjusted linear models.

Results: Patients receiving rivastigmine showed a significantly greater improvement in weekly MoCA scores compared with placebo (mean slope=+0.42 vs. -0.11 points/week; P =0.006; Cohen d=1.40). Memantine was associated with a positive slope (+0.24 points/week), but the effect was not statistically significant after adjusting for baseline cognitive status and covariates.

Conclusions: Rivastigmine may enhance cognitive recovery following ECT. Memantine showed a positive but nonsignificant effect. These findings support the potential utility of cholinergic modulation in mitigating ECT-related cognitive deficits. Future research should explore combination therapies and utilize more sensitive, domain-specific cognitive assessments.

Objectives: Brain tumor-related epilepsy management poses significant challenge in clinical practice. Healthcare providers must tailor treatment based on each patient's unique circumstances. Different antiepileptic drugs can be used, including oxcarbazepine. Several studies show this drug's efficacy and safety in brain tumor-related epilepsy.

Methods: Observational, prospective study, monitoring the efficacy and safety of the drug oxcarbazepine in the prevention of epileptic seizures, included adult patients of both sexes with a supratentorial tumor and a risk of epileptic seizures after neurosurgery.

Results: The study included 153 hospitalized patients. The percentages of amplified waves, sharp waves, and spike waves decreased in the second and third compared with the first visit. Significantly lower percentages of sharp waves ( P = 0.028) on the second compared with the first measurement and spike waves ( P = 0.002) on the third compared with the first measurement were determined. Deterioration from normal to low hemoglobin concentration was observed in 40 (26%) patients at the second visit and 17 (12%) at the third visit, compared with the first visit. However, mean corpuscular volume, mean corpuscular hemoglobin, and mean corpuscular hemoglobin concentration values did not change significantly during the 6 months of follow-up. A transient drop in the number of thrombocytes was observed on the second visit. Adverse reactions to the drug were mild. Therapeutic adherence was low, as measured by the Morisky Medication Adherence Scale (MMAS-4).

Conclusions: The drug oxcarbazepine has shown good efficacy and safety in the prevention of epileptic attacks after neurosurgery in patients with supratentorial tumors. Additional education of patients on the importance of taking regular therapy is crucial.

Objectives: The primary objective of this study was to determine the proportion of patients who developed hemodynamic compromise (HDC) while receiving continuous intravenous midazolam (cIV-MDZ) for refractory status epilepticus (RSE). Secondary objectives included comparing cIV-MDZ and ketamine exposures, baseline and treatment characteristics, and clinical outcomes in patients that developed HDC to those that did not.

Methods: This retrospective nested case-control study included patients receiving cIV-MDZ for RSE at a tertiary academic medical center. Descriptive statistics and univariate analyses were used to compare exposures and outcomes in patients who developed HDC, defined as the initiation or escalation of vasopressors, to those who did not.

Results: Of 112 patients included, 76 (67.9%) developed HDC and 36 (32.1%) did not. Patients who developed HDC received higher mean maximum doses of cIV-MDZ (0.88 mg/kg/h [standard deviation (SD) ± 0.58] vs. 0.55 mg/kg/h [SD ± 0.45], P < 0.001) and longer median durations of cIV-MDZ (2.5 days [interquartile range (IQR), 1.6-3.6] vs. 1.5 days [IQR, 0.7-2.1], P < 0.001). Patients who developed HDC also had longer intensive care unit (ICU) length of stay (13.7 days [IQR, 7.7-19.6] vs. 8.9 days [IQR, 4.7-16.6], P = 0.05) and hospital admissions (21.2 days [IQR, 14.8-30.5] vs. 13.3 days [IQR, 8-23.5], P < 0.01). Seizure recurrence (HDC vs. no HDC, 34.2% vs. 25%; P = 0.33) and mortality (HDC vs. no HDC, 23.7% vs. 19.4%; P = 0.62) were similar between groups.

Conclusions: The majority of patients receiving cIV-MDZ for RSE developed HDC. These results may help guide further studies seeking optimal cIV-MDZ doses for efficacy while minimizing adverse effects.

Abstract: Dextromethorphan, traditionally known as a cough suppressant, is emerging as a potent opioid-sparing analgesic in perioperative pain management. This review explores dextromethorphan's multifaceted role in reducing postoperative pain and minimizing opioid consumption, thus optimizing patient recovery and mitigating adverse effects associated with conventional analgesics. Dextromethorphan operates through diverse mechanisms, including N -methyl- d -aspartate receptor antagonism, sigma-1 receptor agonism, and the inhibition of serotonin and norepinephrine reuptake, offering a broad therapeutic window across various types of pain, notably perioperative and neuropathic pain. Clinical trials highlight dextromethorphan's efficacy in lowering pain scores and reducing postoperative opioid requirements, aligning with multimodal analgesia principles, and enhancing patient outcomes. For instance, studies have demonstrated significant reductions in pain and opioid use postsurgery, without compromising safety or recovery milestones. However, dextromethorphan's effectiveness varies, with limited impact in conditions such as postherpetic neuralgia, underscoring the need for tailored pain management strategies. Incorporating dextromethorphan into perioperative protocols demonstrates its potential in reducing opioid reliance, a crucial aspect amid the opioid crisis. This review concludes that dextromethorphan, while requiring further research to fully elucidate its role in pain syndromes and establish comprehensive dosing guidelines, represents a promising adjunct in effective multimodal analgesia, marking a step forward in improving postoperative care and patient satisfaction.

Objectives: Most patients diagnosed with "sinus headache" are misdiagnosed and mistreated. These patients are often referred to otolaryngology for sinus disease evaluation. However, collaborations between rhinologists and headache specialists for "sinus headaches" have not been investigated. This study aimed to report the clinical features and headache diagnoses of patients referred to headache specialists for prominent craniofacial pain.

Methods: We conducted a retrospective study of patients presenting with craniofacial pain to rhinologists and subsequently referred to a headache specialist for presumed, nonsinogenic, craniofacial pain. Records from a total of 98 patients were reviewed, and information regarding demographics, gender, nasal endoscopy findings, SNOT-22 (Sino-Nasal Outcome Test-22 questionnaire) score, ICHD (International Classification of Headache Disorders) headache diagnosis, and headache characteristics were extracted.

Results: Nasal endoscopies performed by the rhinologists were normal in 92.7% of patients, edema was noted in 5.2% of patients, and mucopurulence in 2% of patients. The majority of patients described their pain as frontal or frontal-maxillary, dull or throbbing, and moderate to severe. Migraine was the most common final diagnosis in 49.1% of patients and the second most common diagnosis was tension-type headache in 17.3%. The remaining patients were diagnosed with 11 additional ICHD diagnoses.

Conclusions: Patients referred from a rhinologist to a headache specialist for nonsinogenic craniofacial pain are frequently diagnosed with primary headache disorder, specifically migraine or tension-type headache. Collaboration between specialists may improve diagnostic accuracy and outcomes, although further studies are crucial.

Objective: Autism spectrum disorder (ASD) is a common neurodevelopmental condition marked by difficulties in social communication and interaction, along with the presence of repetitive behaviors or interests. ASD often co-occurs with attention deficit hyperactivity disorder (ADHD), and this comorbidity should be considered when developing a treatment plan. Methylphenidate (MPH) is a psychostimulant that is commonly used as the first-line treatment for ADHD. Despite its high effectiveness, adverse effects may occur especially in children with co-occurring ASD. Here, we aimed to present a case with ASD and ADHD who developed stuttering with the onset of MPH and discuss the literature.

Method and results: A 10.5-year-old boy with ASD was referred to our clinic due to symptoms of inattention, hyperactivity, and impulsivity. He was diagnosed with ADHD and prescribed OROS MPH at 18 mg/day, which was increased to 27 mg/day after 1 month. His ADHD symptoms moderately improved, but he began stuttering 1 week after the dosage increase. After discontinuing the medication, his speech fluency significantly improved. Three months later, OROS MPH was reintroduced at 27 mg/day, and the stuttering resumed. Consequently, MPH was discontinued, and his treatment is now being managed with atomoxetine.

Conclusions: Despite that the relationship between MPH and stuttering is not well-documented, it is important to recognize that side effects may arise when initiating treatment or increasing the dosage. Typically, quitting the medication is sufficient to alleviate these side effects. Further studies are needed to better understand the side effects and mechanisms of action associated with MPH.