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Yerevanian B.I.,Sepulveda Ambulatory Care Center
Bipolar disorders | Year: 2013

To examine the impact of psychotropic drugs on suicide and suicidal behaviors in bipolar disorders. A Medline search of articles published from January 1960 to January 2013 was performed using relevant keywords to identify studies examining the relationship of psychotropic drugs to suicidal behaviors. The publications were further reviewed for relevant references and information. Additionally, the US Food and Drug Administration Center for Drug Evaluation Research website was searched. The available studies used differing methodologies, making interpretation of the findings difficult. Studies suggest that antidepressants may increase suicidal risk in bipolar disorder, this possibly being related to the induction of broadly defined mixed states. There is no evidence that antiepileptic drugs as a class increase suicidal risk in patients with bipolar disorder. Only lithium provides convincing data that it reduces the risk of suicide over the long term. There is little known regarding the effects of antipsychotics, as well as anti-anxiety and hypnotic drugs, on suicidal behavior. The available evidence for the impact of psychotropics on suicidal risk in patients with bipolar disorder is largely methodologically flawed and, except for a few instances, clinically not useful at this point. Adequately powered, prospective randomized controlled studies are needed to assess the impact of each class of psychotropic and each psychotropic as well as common combination therapies. Until such studies have been carried out, clinicians are urged to exercise caution in using these drugs and rely on the traditional means of carefully assessing and monitoring patients with bipolar disorder who are at high risk for suicide. Published 2013. This article is a U.S. Government work and is in the public domain in the USA. Source


Leung F.W.,Sepulveda Ambulatory Care Center | Leung F.W.,University of California at Los Angeles
Gastroenterology Clinics of North America | Year: 2013

Water-aided methods for colonoscopy include the established water immersion and the recent novel modification of water exchange. Water immersion entails the use of water as an adjunct to air insufflations to facilitate insertion. Water exchange evolved from water immersion to facilitate completion of colonoscopy without discomfort in unsedated patients. Infused water is removed predominantly during insertion rather than withdrawal. A higher adenoma detection rate has been reported with water exchange. Aggregate data of randomized controlled trials suggest that water exchange may be superior to water immersion in attenuating colonoscopy discomfort and optimizing adenoma detection, particularly in the proximal colon. © 2013. Source


Cadoni S.,Digestive Endoscopy Unit | Sanna S.,Digestive Endoscopy Unit | Gallittu P.,Digestive Endoscopy Unit | Argiolas M.,Digestive Endoscopy Unit | And 5 more authors.
Gastrointestinal Endoscopy | Year: 2015

Background: A recent American Society for Gastrointestinal Endoscopy Technology Status Evaluation Report recommended comparative studies of water-aided colonoscopy methods to refine the optimal insertion technique. Objective: Air insufflation (AI), water immersion (WI), and water exchange (WE) were compared head-to-head to test the hypothesis that WE produces the least insertion pain. Design: Patient-blinded, prospective, randomized, controlled trials. Setting: Two community hospitals in Italy. Patients: First-time diagnostic or screening colonoscopy in unsedated patients with the option of on-demand sedation. Intervention: Colonoscopy with AI, WI, or WE. Main Outcome Measurements: Real-time maximum insertion pain (0 = none, 10 = worst). To avoid interventional bias, the timing of recording was at the discretion of the nurse assistant. Adjunct measures were implemented to ensure patient perception of minimal discomfort. Recalled pain and patients' guess of insertion methods were recorded after colonoscopy. Results: Results were merged for 576 randomized patients. Correct patient guesses lower than 33% confirmed adequate blinding. Significant correlation (Pearson coefficient 0.6, P < .0005) between real-time and recalled pain provided internal validation of the former as the primary outcome. Real-time pain (95% confidence interval [CI]: AI, 4.1 [3.7-4.5]; WI, 3.5 [3.0-3.9]; and WE, 2.5 [2.2-2.9] [P < .0005] was the lowest in the WE group. The proportions of patients completing unsedated colonoscopy based on the assigned methods were significantly different (WE, 74.7% vs WI, 62.4%; P = .009; vs AI, 65.3%; P = .04). WE required the least implementation of adjunct maneuvers. Limitations: Unblinded colonoscopists. Conclusion: The current findings with an internally validated primary outcome in adequately blinded patients support the hypothesis that WE is superior to WI in attenuating real-time insertion pain and enhancing completion of unsedated colonoscopy. Copyright © 2015 by the American Society for Gastrointestinal Endoscopy. Source


Yen A.W.,Sacramento Veterans Affairs Medical Center | Yen A.W.,University of California at Davis | Leung J.W.,Sacramento Veterans Affairs Medical Center | Leung J.W.,University of California at Davis | And 2 more authors.
Gastrointestinal Endoscopy | Year: 2013

Background: Water exchange provides salvage cleansing and improves adenoma detection, but drawbacks include prolonged procedure time. Cap-assisted colonoscopy decreases cecal intubation time but is limited by impaired views when feces lodge in the cap. Objective: To investigate the impact of combined water-exchange and cap-assisted colonoscopy (WCC) on detection of adenomas and proximal colon serrated polyps. Design: Retrospective, single-center, single-colonoscopist, consecutive group observational study. Setting: Veterans Affairs outpatient endoscopy suite. Patients: Outpatients undergoing screening or surveillance colonoscopy. Intervention: WCC data collected from 100 consecutive patients were compared to a control group of 101 consecutive patients examined with conventional air insufflation colonoscopy during the prior 4-month period. Main Outcome Measurements: Adenoma detection rate (ADR), adenomas detected per colonoscopy, proximal colon serrated polyp detection rate, and proximal colon serrated polyps per colonoscopy rate. Results: Compared with controls, the WCC group had a higher polyp detection rate (93.0% vs 84.2%; P =.07), ADR (75.0% vs 59.4%; P =.02), proximal colon ADR (61.0% vs 47.5%; P =.07), proximal colon serrated polyp detection rate (24.0% vs 9.9%; P =.009), number of adenomas per colonoscopy (2.70 vs 1.50; P =.002), and mean number of proximal colon serrated polyps per colonoscopy (0.38 vs 0.12; P =.004). Limitations: Retrospective study; single, unblinded endoscopist. Conclusion: ADR and adenomas per colonoscopy are both sensitive indicators of colonoscopy quality. WCC merges two simple methods to improve the performance of screening and surveillance colonoscopy. The data suggest that larger, prospective studies are necessary to determine if there are differences between water-exchange combined with cap-assisted maneuvers and the individual components used alone in lesion detection in screening and surveillance colonoscopy. Copyright © 2013 by the American Society for Gastrointestinal Endoscopy. Source


Leung F.W.,Sepulveda Ambulatory Care Center | Leung F.W.,University of California at Los Angeles
Progress in Drug Research | Year: 2014

Laboratory studies support a role of capsaicin as an anti-obesity agent. Intestinal mucosal afferent nerves appear to play a role in controlling adipose tissue distribution between visceral and subcutaneous sites. Activation of the transient receptor potential vanilloid-1 channels by capsaicin prevents adipogenesis. A neurogenic mechanism modulates the regulation of fat metabolism by transient receptor potential vanilloid-1-sensitive sensory nerves. A neural pathway enables the selective activation of the central network that regulates brown adipose tissue sympathetic nerve activity in response to a specific stimulation of gastrointestinal transient receptor potential channels. Dietary capsaicin reduces metabolic dysregulation in obese/diabetic mice by enhancing expression of adiponectin and its receptor. The effects of capsaicin in adipose tissue and liver are related to its dual action on peroxisome proliferator-activated receptor alpha and transient receptor potential vanilloid-1 expression/activation. Local desensitization of the abdominal capsaicin-sensitive fibers attenuates the hypometabolic adaptation to food deprivation. Truncal vagotomy leads to significant reductions in both diet-induced weight gain and visceral abdominal fat deposition. Vagal de-afferentation leads to a more modest, but clinically and statistically significant, reduction in visceral abdominal fat. Thermogenesis and lipid metabolism-related proteins are altered upon capsaicin treatment in white adipose tissue. Capsaicin induces apoptosis and inhibits adipogenesis in preadipocytes and adipocytes. Epidemiologic data show that consumption of foods containing capsaicin is associated with a lower prevalence of obesity. Clinical evidence supports a role of capsaicin as an anti-obesity agent. Both oral and gastrointestinal exposure to capsaicin increase satiety and reduce energy and fat intake; the stronger reduction with oral exposure suggests a sensory effect of capsaicin. Bioactive components containing capsaicin may support weight maintenance after a hypocaloric diet. Capsaicin consumption 1 h before low intensity exercise is a valuable supplement for the treatment of individuals with hyperlipidemia and/or obesity because it improves lipolysis. Capsinoid ingestion increases energy expenditure through the activation of brown adipose tissue in humans. Capsinoid ingestion is associated with an increase in fat oxidation that is nearly significant; and two common genetic variants may be predictors of response. Further clinical research to develop convenient approaches for obese individuals to take advantage of this common dietary ingredient to prevent the onset or curtail the progression of obesity will be instructive and clinically relevant. © Springer Basel 2014. Source

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