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71: Clin Sports Med. 2005 Apr;24(2):381-413, xii.
Circadian phase shifting, alerting, and antidepressant effects of bright light treatment.
Postolache TT, Oren DA.
Department of Psychiatry, University of Maryland School of Medicine, 685 West
Baltimore Street, Baltimore, MD 21201, USA. firstname.lastname@example.org
Bright light treatment is the most potent melatonin suppressor and circadian phase shifter and is a safe nonpharmacologic antidepressant for seasonal depression. In addition, bright light treatment may restore performance in conditions of sleep debt and misalignment between peak performance and the athletic event. This article discusses the therapeutic use of bright light treatment, its side effects, and mechanisms of action.
72: Klin Monatsbl Augenheilkd. 2005 Mar;222(3):258-60.
Blackening of a choroidal hemangioma after photodynamic therapy.
Bosch MM, Helbig H.
Department of Ophthalmology, University Hospital Zurich, Zurich, Switzerland.
BACKGROUND: Photodynamic therapy has recently advanced to a first line treatment
of symptomatic circumscribed choroidal hemangiomas. HISTORY AND SIGNS: A sixty-year-old
male patient was referred with progressive visual loss in his left eye. Visual acuity measured 20/80 and fundus examination revealed a prominent red subretinal lesion superior to the fovea with adjacent pigment epithelial irregularities. Thickening of the central retina was seen on OCT imaging. Sonography revealed a dome-shaped lesion with a maximal thickness of 3.3 mm and high internal reflectivity. Combined fundus indocyanine green and fluorescein angiography showed early filling of large vessels within the tumor. THERAPY AND OUTCOME: The hemangioma was treated with verteporphin photodynamic therapy. Two days after treatment, with vision unchanged, fundus examination revealed blackening of the tumor. Two months later vision increased to 20/40 and the tumor area was atrophic and bright red with a slight hyperpigmented rim. Angiography revealed the disappearance of tumor vessels and choroidal hypoperfusion in the area of treatment. CONCLUSIONS: Choroidal hemangiomas may darken initially after photodynamic therapy. This is most probably caused by large coaguli within the voluminous lacuna-like blood-filled vessel system of the hemangioma that are induced by photothrombosis.
73: Magnes Res. 2005 Mar;18(1):19-34.
Magnesium depletion with hypo- or hyper- function of the biological clock may be involved in chronopathological forms of asthma.
Durlach J, Pagès N, Bac P, Bara M, Guiet-Bara A.
SDRM, Université Pierre et Marie Curie, 75252 Paris Cedex 05, France. email@example.com
Asthma is a chronic, inflammatory disorder of the airways leading to airflow limitation. Its worldwide rise, mainly in developed countries, is a matter of concern. Nocturnal asthma (NA) frequently occurs and concerns two thirds of asthmatics. But, it remains controversial whether NA is a distinct entity or is a manifestation of more severe asthma. Generally, it is considered as an exacerbation of the underlying pathology. The pathological mechanisms most likely involve endogenous circadian rhythms with pathological consequences on both respiratory inflammation and hyperresponsiveness. A decrease in blood and tissue magnesium levels is frequently reported in asthma and often testifies to a true magnesium depletion. The link with magnesium status and chronobiology are well established. The quality of magnesium status directly influences the Biological Clock (BC) function, represented by the suprachiasmatic nuclei and the pineal gland. Conversely, BC dysrythmias influence the magnesium status. Two types of magnesium deficits must be clearly distinguished: deficiency corresponding to an insufficient intake which can be corrected through mere nutritional Mg supplementation and depletion due to a dysregulation of the magnesium status which cannot be corrected through nutritional supplementation only, but requires the more or less specific correction of the dysregulation mechanisms. Both in clinical and in animal experiments, the dysregulation mechanisms of magnesium depletion associate a reduced magnesium intake with various types of stress including biological clock dysrhythmias. The differenciation between Mg depletion forms with hyperfunction of BC (HBC) and forms with hypofunction of BC (hBC) is seminal and the main biological marker is melatonin (MT) production alteration. We hypothesize that magnesium depletion with HBC or hBC may be involved in chronopathological forms of asthma. Nocturnal asthma would be linked to HBC, represented by an increase in MT levels. The corresponding clinical forms associate diverse expressions of nervous hypoexcitability such as depression, cluster headaches, dyssomnia, mainly advanced sleep phase syndrome, some clinical forms of chronic fatigue syndrome and of fibromyalgia. The main comorbidities are depression and/or asthenia. They take place during the night or the "bad" seasons (autumn and winter) when sunshine is at a minimum. The corresponding chronopathological therapy relies on bright light phototherapy sometimes with additional psychoanaleptics. Conversely, asthma forms linked to hBC are less frequently studied as a whole and present a decrease in MT levels. They associate various signs of nervous hyperexcitability such as anxiety, diurnal cephalalgia (mainly migraine), dyssomnia, mainly delayed sleep phase syndrome, and some clinical forms of chronic fatigue syndrome and of fibromyalgia. The treatment relies on diverse forms of "darkness therapy", possibly with the help of some psycholeptics. Finally, the treatment of asthma involves the maintenance of a standard dosing schedule of anti-asthma drugs, a balanced magnesium intake and the appropriate treatment of the chronopathological disorders.
74: Retina. 2005 Feb-Mar;25(2):119-34.
Guidelines for using verteporfin (Visudyne) in photodynamic therapy for choroidal neovascularization due to age-related macular degeneration and other causes: update.
Verteporfin Roundtable Participants.
Guidelines originally were published in 2002 based on best available scientific data as well as consensus of expert opinion in the absence of controlled clinical trial data to assist ophthalmologists with selection of patients for whom photodynamic therapy with verteporfin (Visudyne, Novartis AG, Basel, Switzerland), termed "verteporfin therapy," should be considered, and to offer suggestions regarding initial treatment, follow-up, and additional courses of treatment at follow-up. Consensus was based on results of clinical trials and expert opinion. Additional input and advice were received from representatives on behalf of the American Society of Retina Specialists, the Macula Society, and the Retina Society, as well as principal investigators of randomized clinical trials evaluating verteporfin therapy. Since 2002, additional information relevant to clinical care was published in the peer-reviewed literature; therefore, revisions to the originally published guidelines judged warranted are provided here. Patient selection criteria include the following: (1) in cases due to age-related macular degeneration (AMD), lesion composition of (a) predominantly classic choroidal neovascularization (CNV), (b) occult with no classic CNV with presumed recent disease progression, or © relatively small minimally classic lesions; (2) CNV location subfoveal or so close to the foveal center that conventional laser photocoagulation treatment almost certainly would extend under the center; (3) etiology of CNV from AMD, pathologic myopia, or other causes in which the outcome without treatment is likely to be worse than with treatment; and (4) vision at a level where further loss would be recognized as detrimental to the quality of life of the patient. Criteria include lesion size for AMD patients with either a minimally classic lesion composition (where treatment usually should be considered only for relatively smaller lesions) or occult with no classic lesions (where treatment usually should be considered for relatively smaller lesions or those >4 Macular Photocoagulation Study disc areas with a relatively lower or poorer best-corrected visual acuity) but not patient age, history of systemic arterial hypertension, or prior laser photocoagulation. Therapy should be initiated ideally within 1 week of the initial fluorescein angiogram on which the clinical decision to treat is based. Patients should return for follow-up at least as often as every 3 months (+/-2 weeks) after any initial or subsequent treatment to determine if there is fluorescein leakage from CNV. Additional courses of treatment should be considered as often as every 3 months (+/-2 weeks) if fluorescein leakage from CNV is noted at that time. Additional courses of treatment could be deferred if the biomicroscopic and fluorescein angiographic appearances of the lesion are unchanged and show minimal fluorescein leakage, especially when there is no subretinal fluid or fluorescein leakage from CNV underlying the center of the foveal avascular zone. Patients should avoid exposure of skin or eyes to direct sunlight or bright indoor light for 48 hours after treatment or until resolution of any swelling or discoloration from extravasation. Follow-up of relatively larger minimally classic lesions and occult with no classic lesions that initially do not undergo therapy appears indicated so therapy can be considered if a predominantly classic lesion develops or, in the case of occult with no classic lesions, if visual acuity declines slightly to a lower (poorer) level without a marked increase in lesion size. Additional revisions of these guidelines may be required as new data become available.
Consensus Development Conference
75: Chronobiol Int. 2005;22(3):597-605.
Working under daylight intensity lamp: an occupational risk for developing circadian rhythm sleep disorder?
Doljansky JT, Kannety H, Dagan Y.
The Institute for Sleep and Fatigue Medicine, Chaim Sheba Health Center, Tel-Hashomer,
A 47-yr-old male was admitted to the Institute for Fatigue and Sleep Medicine complaining of severe fatigue and daytime sleepiness. His medical history included diagnosis of depression and chronic fatigue syndrome. Antidepressant drugs failed to improve his condition. He described a gradual evolvement of an irregular sleep-wake pattern within the past 20 yrs, causing marked distress and severe impairment of daily functioning. He had to change to a part-time position 7 yrs ago, because he was unable to maintain a regular full-time job schedule. A 10-day actigraphic record revealed an irregular sleep-wake pattern with extensive day-to-day variability in sleep onset time and sleep duration, and a 36 h sampling of both melatonin level and oral temperature (12 samples, once every 3 h) showed abnormal patterns, with the melatonin peak around noon and oral temperature peak around dawn. Thus, the patient was diagnosed as suffering from irregular sleep-wake pattern. Treatment with melatonin (5 mg, 2 h before bedtime) did not improve his condition. A further investigation of the patient's daily habits and environmental conditions revealed two important facts. First, his occupation required work under a daylight intensity lamp (professional diamond-grading equipment of more than 8000 lux), and second, since the patient tended to work late, the exposure to bright light occurred mostly at night. To recover his circadian rhythmicity and stabilize his sleep-wake pattern, we recommended combined treatment consisting of evening melatonin ingestion combined with morning (09:00 h) bright light therapy (0800 lux for 1 h) plus the avoidance of bright light in the evening. Another 10-day actigraphic study done only 1 wk after initiating the combined treatment protocol revealed stabilization of the sleep-wake pattern with advancement of sleep phase. In addition, the patient reported profound improvement in maintaining wakefulness during the day. This case study shows that chronic exposure to bright light at the wrong biological time, during the nighttime, may have serious effects on the circadian sleep-wake patterns and circadian time structure. Therefore, night bright light exposure must be considered to be a risk factor of previously unrecognized occupational diseases of altered circadian time structure manifested as irregularity of the 24 h sleep-wake cycle and melancholy.
76: J Psychiatry Neurosci. 2005 Jan;30(1):72.
What is the optimal implementation of bright light therapy for seasonal affective disorder (SAD)?
Centre for Addiction and Mental Health, University of Toronto, Toronto, Ont.
77: Med Hypotheses. 2005;65(5):823-8.
Self-management of psychiatric symptoms using over-the-counter (OTC) psychopharmacology: the S-DTM therapeutic model—Self-diagnosis, self-treatment, self-monitoring.
Pharmacological self-management is becoming more widespread in modernizing societies, as part of a general expansion of health care. This may exert a vital corrective balance to the professionalization of health by ensuring that the individual perspective of patients is not neglected. There are many 'good ideas' for new treatments being published which have a plausible scientific rationale for effectiveness and a low likelihood of harm, yet are essentially ignored by mainstream medical research. The most likely avenue for progress is probably the spread of self-management, together with increased sharing of experience via the internet. There is considerable scope for self-management of psychiatric symptoms with psychoactive medication purchased 'over-the-counter' (OTC) and without prescription. A surprisingly wide range of effective psychoactive agents are available with the potential to self-treat many of the common psychiatric problems. These include 'medical' psychopharmacological agents such as analgesics and antihistamines, a plant extract called St. John's Wort (Hypericum), and physical treatments such as early morning bright light therapy. But self-management currently lacks an explicit therapeutic model. A three stage process of S-DTM - self-diagnosis, self-treatment and self-monitoring is proposed and described in relation to psychiatric symptoms. Self-diagnosis describes the skill of introspection to develop awareness of inner bodily states and emotions. A specific sensation is identified and isolated as the 'focal symptom' for subsequent treatment and monitoring. Self-treatment involves choosing a drug (or other therapy) which is intended to alleviate the focal symptom. Self-monitoring entails a continued awareness of the focal system and of general well-being in order to evaluate effect of therapy. Self-monitoring could involve repeated cycles of dose-adjustment, and on-off ('challenge-dechallenge-rechallenge') therapeutic trials. An example of S-DTM applied to psychiatry might include the attempt to alleviate the fatigue and malaise symptoms underlying a 'depressed' mood by using OTC analgesics such as aspirin, paracetamol/acetaminophen, ibuprofen or codeine. Anxiety symptoms might be self-managed either using an 'unofficial SSRI' (selective serotonin-reuptake inhibitor) such as the antihistamines diphenhydramine or chlorpheniramine; or with St John's Wort/hypericum.
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