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Neubauer D.N.,Johns Hopkins Bayview Medical Center
International Review of Psychiatry

Advances in understanding the neurochemistry of sleep and waking have stimulated new pharmacological directions in the treatment of insomnia. While the sedation of historic insomnia medications was discovered serendipitously, now compounds can be developed for specific molecular targets with known sleep-related actions. Numerous investigational compounds, including some entirely novel approaches, are being evaluated currently as possible insomnia treatments. In recent years the US Federal Drug Administration (FDA) has approved medications with new pharmacodynamic and pharmacokinetic properties thereby extending the options for personalized pharmacotherapy. The FDA is reviewing new applications for innovative sleep-promoting medications currently, including suvorexant and tasimelteon. Presently the FDA-approved insomnia treatment medications include benzodiazepine receptor agonists available in immediate-release, extended-release, and alternative delivery oral absorption formulations; a melatonin receptor agonist; and a histamine receptor antagonist. Clinical indications include insomnia associated with difficulty with sleep onset, sleep maintenance, and middle-of-the-night awakenings. Alternative approaches to treating insomnia have included prescription medications employed on an off-label basis for insomnia, over-the-counter sleep aids, and assorted unregulated substances marketed to enhance sleep. © 2014 Institute of Psychiatry. Source

Earley C.J.,Johns Hopkins Bayview Medical Center
The Journal of clinical psychiatry

Restless legs syndrome (RLS) is a common disorder that can have a considerable impact on a patient's functioning and quality of life. The pharmacologic armamentarium for RLS contains dopamine agonists, a-2d ligands, and opioids, among other agents. Each of these types of drugs has strengths and limitations, and treatment selection should be based on the frequency of RLS symptoms and any accompanying pain. Dopaminergic augmentation, which exacerbates RLS symptoms, is the most common and challenging side effect of long-term RLS treatment with dopamine agonists and requires special clinical consideration. Iron status is also important to the effective management of RLS. Source

Scheel Jr. P.J.,Johns Hopkins University | Feeley N.,Johns Hopkins University | Sozio S.M.,Johns Hopkins Bayview Medical Center
Annals of Internal Medicine

Background: Small case series suggest that a combination of my-cophenolate mofetil and prednisone may be an effective treatment for patients with retroperitoneal fibrosis. Objective: To describe the outcomes of adults with retroperitoneal fibrosis who received a combination of prednisone and mycophe-nolate mofetil. Design: Prospective case series of patients followed between 1 April 2005 and 1 July 2009. Setting: Single tertiary care facility. Patients: 28 patients with retroperitoneal fibrosis. Intervention: Prednisone, 40 mg/d, tapered over 6 months, and mycophenolate mofetil, 1000 mg twice daily, for a mean of 24.3 months. Measurements: Clinical course, laboratory assessment, and measurement of periaortic mass. Mean follow-up was 1012 days, and no patients were lost to follow-up. Results: Systemic symptoms resolved in all patients; 89% had a 25% or greater reduction in periaortic mass. Elevated erythrocyte sedimentation rate and serum creatinine level and decreased hemoglobin level normalized in all patients. Disease recurred in 2 of 28 patients. Limitation: This was a small case series. Conclusion: Combined prednisone and mycophenolate mofetil therapy is a potentially effective treatment for retroperitoneal fibro-sis that warrants evaluation in randomized trials. Primary Funding Source: None. © 2011 American College of Physicians. Source

Mammen A.L.,Johns Hopkins Bayview Medical Center
Nature Reviews Neurology

The different autoimmune myopathiesg-for example, dermatomyositis, polymyositis, and immune-mediated necrotizing myopathies (IMNM)g-have unique muscle biopsy findings, but they also share specific clinical features, such as proximal muscle weakness and elevated serum levels of muscle enzymes. Furthermore, around 60% of patients with autoimmune myopathy have been shown to have a myositis-specific autoantibody, each of which is associated with a distinct clinical phenotype. The typical clinical presentations of the autoimmune myopathies are reviewed here, and the different myositis-specific autoantibodies, including the anti-synthetase antibodies, dermatomyositis- associated antibodies, and IMNM-associated antibodies, are discussed in detail. This Review also focuses on a newly recognized form of IMNM that is associated with statin use and the production of autoantibodies that recognize 3-hydroxy-3-methylglutaryl-coenzyme A reductase, the pharmacological target of statins. The contribution of interferon signaling to the development of dermatomyositis and the potential link between malignancies and the initiation of autoimmune myopathies are also assessed. © 2011 Macmillan Publishers Limited. All rights reserved. Source

Gitlin L.N.,Johns Hopkins University | Kales H.C.,University of Michigan | Kales H.C.,Center for Clinical Management Research | Lyketsos C.G.,Johns Hopkins Bayview Medical Center
JAMA - Journal of the American Medical Association

Behavioral symptoms such as repetitive speech, wandering, and sleep disturbances are a core clinical feature of Alzheimer disease and related dementias. If untreated, these behavior scan accelerate disease progression, worsen functional decline and quality of life, cause significant caregiver distress, andresult in earlier nursing home placement. Systematic screening for behavioral symptoms in dementia is an important prevention strategy that facilitates early treatment of behavioral symptoms by identifying underlying causes and tailoring a treatment plan. First-line nonpharmacologic treatments are recommended because available pharmacologic treatments are only modestly effective, have notable risks, and do not effectively treat some of the behaviors that family members and caregivers find most distressing. Examples of nonpharmacologic treatments include provision of caregiver education and support, training in problem solving, and targeted therapy directed at the underlying causes for specific behaviors (eg, implementing nighttime routines to address sleep disturbances). Based on an actual case,we characterize common behavioral symptoms and describe a strategy for selecting evidence-based nonpharmacologic dementia treatments. Nonpharmacologic management of behavioral symptoms in dementia can significantly improve quality of life and patient-caregiver satisfaction. ©2012 American Medical Association. All rights reserved. Source

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