LEGA NAZIONALE PROFESSIONISTI COMUNICATO UFFICIALE N. 360 DEL 29 maggio 2006 DECISIONI DELLA COMMISSIONE DISCIPLINARE Si riportano le decisioni assunte nel corso della riunione del 23 maggio 2006 dalla Commissione Disciplinare costituita dall’avv. Stefano Azzali, Presidente, dall’avv. Salvatore Lo Giudice, V. Presidente, dal dott. Gianpaolo Tosel e dall’avv. Lucio Colantu
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Uahsj.ualberta.ca16. Ji JD, Cheon H, Jun JB, Choi SJ, Kim YR, osteoarthritis in guinea pigs. Arthritis & anterior cruciate ligament. J Orthop Res. DH, Kim SY, Sohn J. Effects of peroxisome 28. Setton LA, Elliott DM, Mow VC. Altered O’Connor B, Heck D, Albrecht M Anterior mechanics of cartilage with osteoarthritis: human osteoarthritis and an experimental model of joint degeneration. Osteoarthritis osteoarthritis, not merely of cartilage injury and repair. J Rheumatol. 1991;18:436-446.
29. Woo S, Young E, Suh J, Engevretsen, L. 17. Fahmi H, Di Battista JA, Pelletier JP, Mineau as inducers of osteoarthritis. In: Kuettner F, Ranger P, Martel-Pelletier J. Peroxisome activators inhibit interleukin1-beta induced nitric oxide and matrix metalloproteinase 30. Walsh DA. Pathophysiological mechanisms 18. Francois M, Richette P, Tsagris L, et al. 31. Bonnet CS, Walsh DA. Osteoarthritis, Peroxisome proliferator-activated receptor osteophyte formation during experimental osteoarthritis. Osteoarthritis Cartilage. metalloproteinase-1 via a novel composite 32. Chimich D, et al. Water content alters 25. Hellio le Graverand MP, Eggerer J, Vignon 19. Jiang C, Ting AT, Seed B: PPAR-gamma ligament. J Biomech. 1992; 25(8):831-837.
osteoarthiritis. J Orthop Res. 2002;20:535- Tanzer M, Zukor DJ, Antoniou J, Feige U, Poole AR. Role of interleukin-1 and tumor 20. Ricote M, Li AC, Wilson TM, Kelly CJ, Glass necrosis factor alpha in matrix degradation CK: The peroxisome proliferator-activated of human osteoarthritic cartilage. Arthritis limitations in female soccer players twelve 34. Miller D, Forrester K, Leonard C, Hart DA, years after anterior cruciate ligament injury. Salo P, Bray RC. Endothelial dysfunction 21. Kobayashi T. Notoya K. Naito T. Unno S. Arthritis Rheum. 2004;50(10):3145-3152.
and decreased vascular responsiveness in Nakamura A. Martel-Pelletier J. Pelletier the anterior cruciate ligament deficient JP. Pioglitazone, a peroxisome proliferator- model of osteoarthritis. J Appl Physiol. articular cartilage after transection of the Clinical application and review of typical and atypical
antipsychotics in the treatment of delusional parasitiosis
Nathan Y. Hoy,1 Patricia T. Ting, MSc, MD,2 Stewart Adams, MD3
1Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
2Deparment of Dermatology and Cutaneous Sciences, Department of Medicine, University of Alberta, Edmonton, Canada
3Department of Dermatology, University of Calgary, Calgary, Canada
Correspondence and reprint requests to: Nathan Hoy, #110 Beddington Co-op Mall, 8220 Centre St. N.E., Calgary, Alberta, Canada T3K 1J7, Ph: (780) 289-3383, Fax: (403) 275-1143, Email: [email protected] ABSTRACT
advent of atypical antipsychotics have made of both typical and atypical antipsychotics Background: Delusional parasitosis (DP)
the latter the treatment of choice. Given the paucity of randomized control trials and psychosis characterized by a false belief relatively recent introduction of atypicals, pharmacologics. As well, we aim to provide little is known about their efficacy in the Traditionally, treatment revolved around treatment in a dermatological setting.
typical antipsychotics, especially pimozide. Objective: The purpose of this study is to
Methods: Medline and EMBASE were
Pimozide’s adverse effect profile and the review the evidence for the efficacy and use searched for available literature for both University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 types of antipsychotics used in the treatment presence of parasites under the skin leading to secondary excoriations, lichenification, adverse side effects such as orthostatic completed to allow for discussion of clinical A number of case reports, case series, and Results: Risperidone and olanzapine are
currently the most commonly used atypical that the parasites exist; this stereotypical presentation is referred to as “the matchbox as efficacious as pimozide (full or partial sign.”8 Furthermore, patients may attempt The first double-blind crossover study was remission rates of 68% and 90% respectively to rid these “parasites” with anti-scabetic permethrin cream or even perform harmful fewer side effects. Other atypicals such as skin cleansing rituals with disinfectants patients had a decrease in Brief Psychiatric quetiapine, aripiprazole and paliperidone as well as risperidone long acting injections rates > 75% in a limited number of patients, Treatment of DP requires the differentiation between the primary and secondary forms. Treatment of secondary DP relies on treating the underlying cause or cessation of the Conclusion: Limited clinical studies
offending drug.10 Treatment of primary DP significant improvement in 10 DP patients has mostly revolved around typical and the risperidone and olanzapine as first line newer atypical antipsychotics, which have 3 weeks followed by a relapse following 2 trials are needed. We also review methods weeks of placebo treatment and subsequent to typical antipsychotics. We conducted a improvement when pimozide was restarted. literature search using combinations of the treatment with atypical antipsychotics.
search terms: delusion*, parasitosis, typical, own rating scale using symptoms of DP.13 Keywords: Delusional parasitosis, atypical
atypical, antipsychotics and treatment, in published prior to May 1, 2010. For studies involving typical antipsychotics, only those with n≥20 (including placebo group) were INTRODUCTION
reviewed, since these represent the most The rates of partial and full remission are influential studies on which the basis of typical antipsychotic treatment is formed. Zomer et al. (1998) found a partial to full Due to the relatively recent introduction remission rate of 61% (11 out of 18 patients) belief that one is infected with parasites.1 of atypical antipsychotics in the treatment in patients treated with pimozide compared Thieberge first described this disorder in of DP, the n values for these studies were to 20% (3 out of 15) in the non-treatment 1894, and the name delusional parasitosis significantly smaller; thus sample size was group.16 A survey conducted by Lyell (1983) not used as a definitive exclusion criterion. prevalence of DP is not well established, with pimozide demonstrated full or partial but is considered rare. Overall, the female- atypical. The criteria we considered included to-male ratio of affected individuals is the size of the study, with preference being 67%).17 Partial and full remission of DP in given to larger sample sizes; whether or patients treated with pimozide have been diagnosis being slightly higher for females reported as high as 87% (n = 46)18 to 100% than males (mean age, 50 years to 40 years).3 within the same study, to control for variable The classification of DP is as either primary The long-term efficacy of treatment with or secondary. Primary DP is characterized pimozide was demonstrated in a follow-up by a somatic delusion lasting for at least population with respect to disease severity, study by Lindskov and Baadsgaard (1985).19 Fourteen patients were followed up between criterion A for schizophrenia and there can be no underlying cause of the delusion.4 Typical antipsychotics
substance, organic causes, or other medical used in the treatment of DP is pimozide.11 A systematic review conducted by Lepping events, and neurodegenerative disease. A Gilles de la Tourette syndrome in the United et al. (2007) found a total of 92 patients States, but it has also been shown to have causes of DP is discussed by Huber et al. label disorders, such as DP.10-19 Pimozide’s primary mechanism of action is via central Given that DP is a somatic delusion, patients often initially present to dermatologists improvement or were lost to follow-up.10 Of advantage of pimozide over other typical instead of psychiatrists with symptoms of the 53 patients treated with pimozide, 50 antipsychotics is its weak noradrenergic pruritis, crawling sensations attributed to the had either full or partial remission (94%), University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 Table 1: Efficacy of typical antipsychotics in treatment of DOP
Two lost to follow-up for senility (n=1) and extensive relapse (n=1) Table 2: Efficacy of atypical antipsychotics in treatment of DOP
7 (29) lost to follow up; 4 were switched to other drugs for varying reasons including requiring a different antipsychotic for co-morbid psychiatric disease, and intolerance of risperidone; 1 took it once and refused to continue medication while 3 patients were non-compliant with other hypotheses question this.21, 22 Atypical treatment course – reasons for switching treatment.10 Of note, the sample sizes for the antipsychotics used in the treatment of other typical antipsychotic treatments were DP that will be discussed are risperidone, olanzapine, quetiapine, aripiprazole, and intolerance of risperidone (Table 2).24-28 atypical antipsychotics
The most recent and largest retrospective Atypical antipsychotics differ from typical risperidone as the main treatment modality case study followed 20 patients utilizing antipsychotics in their various mechanisms for DP. Gallucci and Beard23 first established atypical antipsychotics for DP.26 Fifteen of action and are generally associated with risperidone as a potential treatment of DP. patients were treated with risperidone as less extrapyramidal symptoms. Meltzer et Overall, of the 41 cases of DP treated with the main atypical antipsychotic and 10 of al. (1989)20 proposed that a preference for risperidone that we reviewed, 28 had a full them had full or partial remission, while 5 or partial remission, one had no change in were lost to follow-up. Five patients were symptoms and 12 were lost to follow up or treated with olanzapine as the main atypical this class of drugs, although a number of were switched to another drug during the University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 antipsychotic. Of these patients, 4 had full or and Lepping (2008) found a full or partial partial remission, and 1 was lost to follow up.
schizophrenia, and Gilles de la Tourette cases.34 The side effect profile of quetiapine is generally limited to drowsiness, dizziness treated with risperidone and one treated with quetiapine.27 Three of the 4 risperidone-treated patients experienced prolongation, including Torsades de Pointes, risk of extrapyramidal symptoms or adverse total resolution of delusions; one of these cardiac effects.36 Quetiapine’s excellent three patients was also on lithium, another blocking effects of the drug.7, 14, 35 These side side effect profile combined with its high was on sertraline and alprazolam as well, effects, especially its cardiac effects and remission rate makes it a potential treatment The results of aripiprazole treatment in DP patient had a decrease in delusions and was have only been published for 4 patients to on no other medications. The patient treated date with all 4 demonstrating full or partial with quetiapine showed partial remission antipsychotics, because of their relatively and was also on venlafaxine, clonazepam, randomized control trials or placebo cross antipsychotics. The largest review to date over studies performed with aripiprazole promising. Adverse effects of aripiprazole risperidone long-acting injections (RLAI).29 Lepping,34 which concluded that atypical include nausea and akathisia, but it is non- The patient refused to take oral risperidone, but accepted RLAI 25 mg IM every 2 weeks. This dosage was titrated up to 37.5 mg IM The atypical antipsychotics with the largest disturbances.37 This excellent side effect sample sizes in our review were risperidone profile may make it beneficial to DP patients improved, although complete remission was antipsychotic used in the treatment of DP. There are also newer atypical antipsychotics The particular effectiveness of this drug has antipsychotic used in the treatment of DP. been linked to its high affinity for 5-HT Paliperidone is the main active metabolite receptors, a receptor which has been linked of risperidone and it blocks 5-HT and D - receptors. It has a long half-life of 24 hours, aripiprazole.30-32 Rocha and Hara (2007) which decreases the number of daily doses. documented the first case of aripiprazole side effect profile is superior to that of As well, it decreases the risk of any potential typical antipsychotics, there are instances adverse drug reactions, which is especially been produced by its use and it has been associated with a mild increase in metabolic simultaneously.33 The clinical efficacy of had complete remission.31 Paliperidone, an syndrome.32 An added benefit of risperidone paliperidone as a treatment for DP needs atypical antipsychotic approved by the FDA is that it is the only atypical antipsychotic to be confirmed by further case studies or in 2006, has only been used in one DP case, available as a long-acting depot. Long acting randomized control trials.
where an 88 year old man treated with the injections are particularly useful in patients CLINICAL IMPLICATIONS
who are demonstrating harmful behaviours and refusing to comply with oral treatment. Diagnosis of DP is definitely within the DISCUSSION
scope of a dermatology practice. However, to help the patient accept their problem makes initiating therapy in a dermatologist treatment option for DP. The rates of full office challenging. Patients often feel as or partial remission were similar to the if their symptoms are not being seriously numbers reported in a systematic review by Lepping et al. (2007).10 There have been a treatment.34 Its side effect profile is also to explain that the disease is psychotic in number of smaller case reports and studies superior to that of pimozide and it rarely nature. Referral to a psychiatrist is often utilizing other typical antipsychotics such as causes extrapyramidal syndrome. However, met with anger and frustration, resulting haloperidol, trifluoperazine, flupenthixol and this medication is closely associated with in the patient either seeking the opinion metabolic syndrome and sedation.32 Its use of another dermatologist or resorting to excellent rates of full or partial remission.10 is still limited by a smaller body of evidence, self-treatment, which may be potentially Despite the past successes of pimozide, it is but the fact that three patients treated with no longer considered first-line treatment of patient’s thoughts on you consulting an DP, due to the advent of the safer atypical due to intolerance suggests it may be a more conditions more frequently. This will open the door to discussing the management Furthermore, the long-term use of pimozide Quetiapine had an excellent remission rate, plan with a psychiatrist, while empowering but with a small sample size (n=2), more the patient to be actively involved in the studies must be done in order to assess its such as tardive dyskinesia, parkinsonism University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 4. DSM-IV-TR. Diagnostic and statistical 20. Meltzer HY. What’s atypical about atypical antipsychotic drugs? Curr Opin Pharmacol. rather than risk losing rapport with the patient. Koo and Lee (2001) suggest making American Psychiatric Association, 2000.
5. Huber M, Kirchler E, Karner M,Pycha R. D(2) receptors and their role in atypical the patient be more flexible in his or her antipsychotic action: still necessary and thinking if the biopsy returns negative; this transporter. A new insight of etiology? Med may even be sufficient. Biol Psychiatry. may make it easier to convince the patient 6. Donabedian H. Delusions of Parasitosis. 22. Westerink BH. Can antipsychotic drugs be classified by their effects on a particular is initiated, it is advisable to offer the medication as an empirical therapy while 23. Gallucci G, Beard G. Risperidone and the treatment of delusions of parasitosis sensations.8 Potential side effects of the 8. Koo J, Lee CS. Delusions of parasitosis. the patient beforehand, to enhance patient A dermatologist’s guide to diagnosis and compliance. Considering the patient’s co- treatment. Am J Clin Dermatol. 2001;2:285- morbidities when selecting the particular treatment of delusions of infestation. Int J antipsychotic to be used can help tailor the choice; for example, in a patient with 25. Healy R, Taylor R, Dhoat S, Leschynska due to its potential for metabolic syndrome side effects. Depot injections (risperidone) 10. Lepping P, Russell I, Freudenmann RW. dermatology/ liaison psychiatry clinic. Br J if the patient is willing to be regularly delusional parasitosis: systematic review. Br monitored by a psychiatric team. Working in conjunction with the patient’s family Parasitosis: a retrospective case series of 20 physician to monitor both the side effects of patients. Int J Dermatol. 2010; 45:95-100.
the antipsychotic medication and course of review. Am J Clin Dermatol. 2004;5:339-49.
the DP will reduce the risks of complications from the therapy, especially if the patient the treatment of delusional parasitosis. refuses the involvement of psychiatry.
28. Nicolato R, Correa H, Romano-Silva MA, CONCLUSION
Teixeira AL, Jr. Delusional parasitosis or 13. Ungvari G, Vladar K. Pimozide treatment control trial directly comparing atypical for delusion of infestation. Act Nerv Super antipsychotics to typical antipsychotics, clear treatment of choice for DP.10 However, pimozide in clinical psychiatry: a review. J Parasitosis. German Journal of Psychiatry. classes as shown in Tables 1 and 2, it would appear that atypical antipsychotics have a infestation treated by pimozide: a double- delusional parasitosis: Case report. Prog lower side effect profile while achieving a blind crossover clinical study. Acta Derm partial to full remission rate similar to typical antipsychotics. The reduction in adverse 16. Zomer SF, De Wit RF, Van Bronswijk JE, 31. Bennassar A, Guilabert A, Alsina M, Pintor L,Mascaro JM, Jr. Treatment of delusional compliance to treatment and help construct parasitosis. A psychiatric disorder to be treated by dermatologists? An analysis of 33 patients. Br J Dermatol. 1998;138:1030- 32. Sandoz A, LoPiccolo M, Kusnir D, Tausk References:
17. Lyell A. The Michelson Lecture. Delusions of parasitosis. Br J Dermatol. 1983;108:485- parasitosis. Mayo Clin Proc. 2004;79:1470.
2. Wilson J, Miller H. Delusions of Parasitosis. Archives of Dermatology and Syphilology. Delusional parasitosis: a clinical profile. Int paliperidone. Clin Exp Dermatol. 2009;34:375-7.
19. Lindskov R, Baadsgaard O. Delusions of infestation treated with pimozide: a follow- up study. Acta Derm Venereol. 1985;65:267- generation antipsychotics in primary and experience with 23 consecutive cases at an secondary delusional parasitosis: outcome academic medical center. Int J Infect Dis. University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 35. Wykoff RF. Delusions of parasitosis: a review. Rev Infect Dis. 1987;9:433-7.
delusional parasitosis: experience in an Aripiprazole in the treatment of primary 36. Milia A, Mascia MG, Pilia G, Paribello delusional parasitosis. Br J Psychiatry. Stem cells in cardiac repair: A review of the changing
landscape of cardiovascular medicine
Nicholas A. Avdimiretz, BSc
Medical Student (2013), Faculty of Medicine and Dentistry University of Alberta, Edmonton, Canada
Correspondence to Nicholas Avdimiretz: Email: [email protected] Abstract
Introduction to Cardiac Repair
Cardiac disease is the leading cause of death developed countries. In fact, cardiovascular its first applications for reconstituting disease – including coronary heart disease, increased by 90% in middle income groups, hypertension, stroke, and congestive heart failure – has ranked as the number one pancreatic islet transplantation.5 More recent cause of death in the US every year since treatments include those for liver cirrhosis, keep up with these statistics? Imagine if Huntington’s disease, and Parkinson’s epidemic.1 In 2007, heart disease accounted disease.6 As for heart disease, the majority heart post-myocardial infarction, or even for 26% of all deaths in the US, resulting in an age-adjusted death rate of 211 per treatment of heart damage post-myocardial is the future of cardiovascular medicine. 100,000 people.2 Also shocking is the cost infarction (MI). How can myocardial repair Regenerating myocardium is hardly an easy of medication, health care services, and lost undertaking; the heart contains about 20 productivity due to heart disease in the US: incapable of naturally self-repairing itself? million cardiomyocytes per gram of tissue, a projected $508 billion in 2010.3 This cost The heart does not experience regeneration meaning – in the left ventricle alone – there is not expected to decrease any time soon. as the liver does; following MI, scar tissue are approximately 4 billion cardiomyocytes In Canada, the incidence of risk factors for forms over the infarcted area. Therefore, at risk during a heart attack. Many cells are cardiac disease has increased substantially required to replace damaged tissue, making complete regeneration challenging. In light of the rich therapeutic potential seen in both adult and embryonic stem cells, it is no the population),4 resulting in substantially muscle following an MI is hardly an easy surprise that biomedical research on these more cardiovascular disease. What if there cells has seen an intense amount of activity existed a therapeutic technique to treat that about 20 million cardiomyocytes per gram of which physicians have for so long deemed tissue, so there are approximately 4 billion cardiomyocytes and skeletal myoblasts, to incurable? What if one could regenerate the cardiomyocytes at risk in the left ventricle bone marrow stromal cells and peripheral wounded heart after a myocardial infarction blood CD34+ cells, a myriad of cell lines that any repair therapy restores at least have been tested to date. The last decade bioengineer a new heart. This could be the has seen an explosion of novel approaches true regeneration would require 500 to 800 using these cells to restore cardiac function million cells.7 In light of the therapeutic post-infarction: from developing cell-based Over the last decade, the utilization of potential seen in both adult and embryonic pacemakers and cardiac grafts, to building stem cells to repair the damaged heart has stem cells (coined ES cells by Martin in bioartifical hearts. This review will paint a seen an explosion of advancements. Novel 1981),8 it is no surprise that biomedical picture of the rapidly changing landscape therapeutic techniques will be addressed in research on these cells has seen an intense of cardiovascular medicine by elaborating detail: the methods used and the resulting amount of activity in the past decade.
applications of these innovations will be of these approaches will be discussed, as described. Limitations of these techniques Stem Cell Sources
well as future developments. In the field of cell-based cardiac repair, the possibilities capacity to self-renew, but they are also pluripotent; this means that stem cells can be induced to differentiate into cells University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1
Short report Homeopathy service in a National Health Service community menopause clinic: audit of clinical outcomes School of Health and Related Research, University of Sheffield, Sheffield, UKsubstances. These doses (usually in tablet form) are Sheffield’s National Health Service community menopause individually prescribed according to the principle of ‘like clinic has run a