Ronald J. DeBellis

Management of Delirium Tremens

Delirium tremens is recognized as a potentially fatal and debilitating complication of ethanol withdrawal. Research thus far has primarily focused on the prevention of delirium tremens.

Linezolid-Associated Serotonin Syndrome After Concomitant Treatment With Citalopram and Mirtazepine in a Critically Ill Bone Marrow Transplant Recipient

Linezolid was initially discovered as an antidepressant because of its effect on blocking intracellular metabolism of serotonin, norepinephrine, and other biogenic amines. As time passed, it was realized that linezolid possessed antibacterial activity, and linezolid has been developed and marketed as such. In medicine we are quick to categorize drugs into specific classes as a mechanism to recall indication and use. By classifying linezolid as an antibacterial, it is common to forget about its antidepressant roots. A case report involving linezolid with citalopram and mirtazepine in the precipitation of serotonin syndrome in a critically ill bone marrow transplant patient is described in this article.

The effects of Tween-80 on the integrity of solutions of capsaicin: useful information for performing tussigenic challenges

BackgroundBecause variable results of capsaicin challenges may be due to the incomplete solubility of capsaicin, we sought to determine if the use of Tween-80 in solutions of capsaicin improves actual concentrations of freshly prepared and stored solutions.MethodsCapsaicin solutions ranging from 0.5–128 μM were mixed with and without Tween-80. Samples of various concentrations were then stored under 4 environmental conditions: 4°C, protected from light; room temperature, protected from light; room temperature, exposed to light; -20°C. All samples were analyzed initially, and at 2 and 4 months.ResultsWhile freshly prepared solutions with Tween-80 had consistently higher concentrations than those prepared without Tween-80 (83% vs. 69%), Tween-80 does not facilitate complete solubility. For solutions stored at 4°C and protected from light, there was a significant decrease after 2 months in low concentration solutions of both the Tween-80 and non-Tween-80 solutions. Both Tween-80 and non-Tween-80 containing solutions significantly decreased in concentration after 2 months when stored at room temperature and protected from light, room temperature and exposed to light, and -20°C. Concentrations of solutions made of 4 μM or higher are stable when stored at 4°C and protected from light for 4 months.ConclusionWhile the inherent difficulty of forcing capsaicin into solution cannot be eliminated, it can be improved with Tween-80. However, the addition of Tween-80 does not prevent the breakdown of stored capsaicin solutions. We recommend preparing and storing capsaicin solutions according to the methods and results of this study.

Mechanism of Action of Long-Acting Bronchodilators

It has been suggested that the pathophysiology of chronic obstructive pulmonary disease is characterized by a centrally mediated increase in cholinergic tone. β-Agonists act by binding to adrenergic receptors, which stimulate bronchodilation through the mediation of the cyclic AMP (cAMP) second messenger system. Theophylline is postulated to stimulate bronchodilation by inhibiting phosphodiesterase and adenosine. Phosphodiesterase inhibition prolongs the actions of cAMP and results in bronchodilation. Inhaled long-acting anticholinergics work by antagonizing the actions of acetylcholine, producing relaxation of airway smooth muscle.

State of the Art Reviews: Nonpharmacologic Approaches for the Treatment of Insomnia

Insomnia is a common condition resulting in significant clinical and economic consequences. This review discusses the efficacy of nonpharmacologic treatment options commonly recommended for sleep onset and sleep maintenance insomnia. In addition, the efficacy of these approaches as part of a multifaceted intervention and in comparison to that of pharmacologic options is reviewed. The primary literature and review articles on the nonpharmacologic treatment of insomnia were identified through a MEDLINE search between 1966 and August 2006. Articles on the nonpharmacologic treatment of primary insomnia, including clinical trials on the efficacy of individual and combination treatment options, were reviewed. The nonpharmacologic treatment options for insomnia include stimulus control, sleep hygiene educations, sleep restriction, paradoxical intention, relaxation therapy, biofeedback, and cognitive-behavioral therapy. These treatment strategies produce significant changes in several sleep parameters of chronic ...

State of the Art Review: Long-term Pharmacotherapy for Overweight and Obesity: A Review of Sibutramine, Orlistat, and Rimonabant

The objective of this review is to evaluate the safety and efficacy of pharmacotherapy for long-term maintenance of weight loss in overweight and obese patients. Literature was obtained through a MEDLINE (1966 to July 2006) search and a bibliographic review of published articles. Key terms used included overweight, obesity, sibutramine, orlistat, and rimonabant. The search was further limited to clinical trials in humans and in the English language. Obesity is a chronic condition requiring long-term therapy. Two agents, sibutramine and orlistat, are currently approved by the Food and Drug Administration for the long-term treatment of obesity. Rimonabant, marketed in Europe as Accomplia, has demonstrated efficacy for long term weight loss, however an Food and Drug Administration advisory panel voted against its approval in June 2007 due to safety concerns (psychiatric effects). For clinically meaningful results, these agents must be used in conjunction with lifestyle therapy, including a hypocaloric diet, ...

Pharmacotherapy of High-Altitude Illness

High-altitude illness (HAI) encompasses an array of conditions that may occur in individuals who travel to high elevations, including acute mountain sickness, high-altitude cerebral edema, and high-altitude pulmonary edema. Individuals with a history of HAI are predisposed to developing HAI; however, other risk factors are not well defined. The primary method of preventing HAI is acclimatization through gradual ascent to high altitude. In addition, many studies have assessed the use of pharmacologic prophylaxis. The most studied and widely recommended prophylactic agent is acetazolamide; additional agents that have been considered include dexamethasone, Gingko biloba, antioxidant vitamins, nifedipine, aspirin, and salmeterol. The treatment of choice for all forms of HAI is descent to lower altitude. The use of additional treatments, including supplemental oxygen, varies depending on the severity of the clinical presentation. Acetazolamide and dexamethasone have been studied as adjunctive treatments for acute mountain sickness, while nitric oxide and nifedipine have been evaluated for the treatment of high-altitude pulmonary edema. Data with analgesics and phosphodiesterase-5 inhibitors, while limited, are promising. This review will present the evidence supporting the use of pharmacotherapy for prevention and treatment of HAI.

State of the Art Reviews: Smoking Cessation A Review of Treatment Considerations

Smoking cessation continues to be an area of great concern for public health. Smoking status and willingness to quit should be assessed at every patient visit. A variety of nonprescription and prescription pharmacotherapy options exist for those willing to quit. Medications currently approved by the Food and Drug Administration for smoking cessation include nicotine replacement therapy (gum, lozenge, patch, inhaler, and nasal spray), bupropion sustained release, and the newly approved varenicline. Nortriptyline and clonidine are not indicated for smoking cessation but have been used as second-line agents. This review focuses on each treatment option, including precautions, proper dosing and duration, adverse effects, and medication delivery issues. Attention is also given to individual patient considerations such as combination therapy, pregnancy, postcessation weight gain, and effects of cessation on the current medication regimen.

Resistance: Mechanisms and influencing factors

A lthough most antibiotics used today became available after 1981, the incidence of death from infectious diseases has risen. From 1980 to 1992, there was a 58% increase in the death rate due to infectious diseases as the underlying cause. Death due to respiratory tract infections increased by 20% in that time frame and the rate of death due to septicemia increased 83%. Factors that may have contributed to this increase include changes in the spectrum or virulence of etiologic pathogens and antibiotic resistance. How important is the development of antibiotic resistance and what factors influence it? This article will examine these questions, focusing on the mechanisms of resistance and the potential impact of pharmacokinetic and pharmacodynamic profiles of frequently used antibiotics on resistance.

Antibiotic-resistant pathogens-epidemiology and clinical relevance

In the early days of antibiotic development, penicillin, sulfa, and early macrolide antibiotics were the mainstay of antimicrobial therapy. At this time Gram-positive pathogens were of major concern. With the advent of methicillin and vancomycin in the 1960s, Gram-positive pathogens were considered to be less of a problem. The focus on treating Gram-negative pathogens began in the 1970s. Thus, in the 1980s, the pharmaceutical industry concentrated antibiotic development efforts on treating these pathogens. The antibiotics developed were described as “broad spectrum” and covered far more than the original target organisms. The culture moved from one of treating not only Gram-positive organisms, but to treating enteric and nosocomial Gram-negative organisms. Over time, it has become clear that use of broadspectrum antibiotics (advanced-generation cephalosporins, fluoroquinolones, and advanced-generation macrolides) has placed selective pressure on antimicrobial flora. This selected pressure has presented new challenges in antibiotic resistance in both Gram-positive and Gram-negative organisms.