Gene/Protein Disease Symptom Drug Enzyme Compound
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Query: UMLS:C0917801 (insomnia)
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We observed six cases of patients in a dialysis programme who were apparently intoxicated by ingestion of star fruit. After ingestion of 2-3 fruits or 150-200 ml of the fruit juice, the six patients, who had previously been stable in a regular dialysis programme, developed a variety of symptoms ranging from insomnia and hiccups to agitation, mental confusion and (in one case) death. In preliminary investigations to characterize the hypothetical neurotoxin in the fruit, an extract, when injected intraperitoneally or intracerebroventricularly in rats, provoked persistent convulsions of the tonic-clonic type. It appears that star fruit (Averrhoa carambola) contains an excitatory neurotoxin. Patients with renal failure on conservative or dialysis treatment should be dissuaded from ingestion of the fruit.
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PMID:Intoxication by star fruit (Averrhoa carambola) in six dialysis patients? (Preliminary report) 955 Jun 29

The adequate primary care of patients with renal failure, from the choice of the modality of treatment down to the everyday answering of questions of patients, relatives, and staff, requires a knowledge of the major psychological stresses of the illness and the psychiatric complications resulting from these stresses and their treatment. Among the major stresses of dialysis are the procedure itself, the overall medical treatment which includes medications and diet, and dependency-independence issues arising from the unique and almost abject dependency of patients on a machine, a procedure, and a group of medical professionals. As a result of these physical and psychological stresses, the disorders seen include delirium, depression, anxiety, suicide, uncooperative behavior, sexual dysfunctions, and psychosis. In their treatment, one should first consider what prophylactic steps should be taken to avoid their occurrence. It is best that a behaviorally trained professional be involved in the initial evaluation of all prospective patients. Ideally this should be a consultation-liaison psychiatrist. Such involvement may help in the selection of a modality of treatment best suited for the psychosocial background of the patient and help identify those most susceptible to psychiatric symptoms and disorders. Patients should be told of the possibility of complications such as sexual dysfunctions and, in the case of dialysis patients, that they may at some point in the course of their treatment consider voluntary withdrawal from it. Medications have an important role in the treatment of anxiety, insomnia, depression, psychosis, and sexual dysfunctions. Concerning the latter, behavioral techniques of Masters and Johnson have been found to be useful. Talking therapies seem to be of value for only to a limited number of motivated patients.
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PMID:Psychiatric considerations in the primary medical care of the patient with renal failure. 1092 11

Patients with end-stage renal failure (ESRF) are reported to have a high prevalence of sleep disorders, such as daytime sleepiness, insomnia, restless legs syndrome (RLS), and obstructive sleep apnea syndrome (OSAS). However, there are few published data from Southeast Asia. A sleep questionnaire was administered to 201 patients (103 men) at the continuous ambulatory peritoneal dialysis (CAPD) outpatient clinic to assess sleep problems. Patients had a mean age of 56.7 +/- 12 (SD) years, with a mean body mass index (BMI) of 23.6 +/- 3.5 kg/m(2). Daytime sleepiness was the most frequent symptom (77.1%), and frequent awakening occurred in 69% of the patients. Sleep-onset insomnia and sleep-maintenance insomnia occurred in 73% and 60% of the patients, respectively. Sixty-two percent of the patients reported symptoms of RLS, which significantly correlated with sleep-onset insomnia (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.5 to 5.5; P = 0.001) and sleep-maintenance insomnia (OR, 2.1; 95% CI, 1.2 to 3.8; P = 0.014). The prevalence of OSAS was estimated by the frequency of the following symptoms: extremely loud snoring, 7 patients (3.5%); observed choking, 21 patients (10.5%); witnessed apnea, 11 patients (5.6%); snoring and witnessed apnea, 6 patients (3%); disruptive snoring, 29 patients (14.4%); and disruptive snoring and witnessed apnea, 3 patients (1.5%). This questionnaire survey confirmed a high prevalence of daytime sleepiness, insomnia, and RLS in patients with ESRF undergoing CAPD but showed a relatively low prevalence of OSAS of up to 14.4%, which may be related to the low BMI of these patients with ESRF compared with other populations. Whether this contributes to the overall better survival observed in some Asian patients with ESRF undergoing dialysis needs further investigation.
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PMID:Prevalence of sleep disturbances in chinese patients with end-stage renal failure on continuous ambulatory peritoneal dialysis. 1100 81

Geriatric patients with major depression present clinical challenges not encountered in younger individuals, including a greater incidence of medical comorbidity, higher rates of multiple medication use, changes in drug metabolism due to age or physical illness, and increased sensitivity to antidepressant side effects. Nevertheless, successful treatment of depressive disorders in the elderly improves mental and physical functioning, decreases morbidity and perhaps mortality, and enhances quality of life. Recent research indicates that newer antidepressants are effective for late life depression and safer for older individuals. Among newer antidepressants, venlafaxine has a pharmacological profile that makes it an attractive choice for geriatric patients. It has limited potential to interact with other medications because it only weakly inhibits the cytochrome P450 system and binds to plasma proteins at a low level. Dosing may have to be adjusted for patients with renal failure, but typically not for those with liver disease or other medical conditions. Data from three double-blind and four open clinical trials support the safety and efficacy of venlafaxine for geriatric depression. Patients may experience transient, generally tolerable side effects such as insomnia, nausea, agitation, or dry mouth early in treatment, but more serious problems such as falls or cardiac rhythm disturbances seem to be rare. Treatment emergent hypertension occurs in a small percentage of older patients, generally at doses above 150 mg/day. Finally, emerging data suggest that venlafaxine may be effective for conditions such as stroke, anxiety, and neuropathic pain that frequently accompany depressive disorders in the elderly.
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PMID:Efficacy of venlafaxine in geriatric depression. 1109 16

Depressive and anxiety disorders appear during the transplant process due to psychological stressors, medications and physiological disturbances. Treatment is necessary to prevent impact on patient compliance, morbidity and mortality. Psychotropic medications provide an effective option, although most are only available as oral formulations. Because of this, they are more susceptible to alterations in pharmacokinetic behaviour arising from organ dysfunction in the pretransplant period. Kinetics are also an issue when considering potential drug-drug interactions before and after transplantation. Prior to transplant, organ dysfunction can change the pharmacokinetic behaviour of some psychotropic agents, requiring adjustment of dosage and schedules. Thoracic or abdominal organ failure may reduce drug absorption through disturbances in intestinal motility, perfusion and function. Cirrhotic patients experience increased drug bioavailability due to portosystemic shunting, and thus dosage is adjusted downward. In contrast, dosage needs to be raised when peripheral oedema expands the drug distribution volume for hydrophilic and protein-bound agents. Drug clearance for most psychotropic medications is dependent upon hepatic metabolism, which is often disrupted by endstage organ disease. Selection of drugs or their dosage may need to be adjusted to lower the risk of drug accumulation. Further adjustments in dosage may be called for when renal failure accompanies thoracic or abdominal organ failure, resulting in further impairment of clearance. Studies regarding the treatment of anxiety and depressive disorders in the medically ill are limited in number, but recommendations are possible by review of clinical and pharmacokinetic data. Selective serotonin reuptake inhibitors are well tolerated and efficacious for depression, panic disorder and post-traumatic stress disorder. Adjustments in dosage are required when renal or hepatic impairment is present. Among them, citalopram and escitalopram appear to have the least risk of drug-drug interactions. Paroxetine has demonstrated evidence supporting its use with generalised anxiety disorder. Venlafaxine is an alternative option, beneficial in depression, post-traumatic stress and generalised anxiety disorders. Nefazodone may also be considered, but there is some risk of hepatotoxicity and interactions with immunosuppressant drugs. Mirtazapine still needs to be studied further in anxiety disorders, but can be helpful for depression accompanied by anorexia and insomnia. Bupropion is effective in the treatment of depression, but data are sparse about its use in anxiety disorders. Psychostimulants are a unique approach if rapid onset of antidepressant action is desired. Acute or short-term anxiolysis is obtained with benzodiazepines, and selection of particular agents entails consideration of distribution rate, half-life and metabolic route.
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PMID:Treatment of anxiety and depression in transplant patients: pharmacokinetic considerations. 1508 75

Restless legs syndrome (RLS) is characterised by an urge to move the legs, uncomfortable sensations in the legs and worsening of these symptoms during rest with at least temporary relief brought on by activity. RLS occurs in 3-15% of the general population and in 10-30% of patients on maintenance dialysis. RLS may lead to severe sleep onset or maintenance insomnia, and greatly impaired quality of life. Current recommendations suggest dopaminergic therapy (levodopa or dopamine receptor agonists: pramipexol, ropinirole, pergolide or cabergoline) as the first-line treatment for RLS. This group of medications is effective in reducing RLS symptoms in the general population; limited information is available on the effect of these drugs in patients with renal failure. However, it must be noted that most published studies in uraemic patients had short treatment periods and insufficient statistical power because of small sample size. Frequent adverse effects of levodopa, seen mainly with continuous use, may limit its use significantly. Rebound and augmentation, problems relatively frequently seen with levodopa, seem to be less prevalent with the use of dopamine receptor agonists, although properly designed comparative trials are still needed to address this question. Alternative treatment options for RLS are gabapentin, benzodiazepines and opioids. For all of these medications, there are only very limited data available on their effectiveness and safety profile in patients on maintenance dialysis. Referral to a specialist for RLS management should be considered for patients with refractory RLS.
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PMID:Management of restless legs syndrome in patients on dialysis. 1662 Jan 40

The Children's Analgesic Medicine Project (CAMP) was a multicenter, all-comers, openlabel, prospective study to compare the safety of ibuprofen suspension with acetaminophen suspension in children with fever and/or pain. Four hundred and twenty four (424) pediatricians enrolled 41 810 children (aged 1 month to 18 years old) at 69 US clinics. Safety data included information concerning medication use and adverse events (AEs) summarized by severity and analyzed by age groups (younger and older than 2 years). Among 30 144 children who took at least one dose of ibuprofen or acetaminophen, 14 281 were younger (< 2 yrs) and 15 863 were older ([Symbol: see text] 2 to < 12 yrs). Within both age groups, the incidence rates for specific AEs, including abdominal pain, insomnia, and hyperkinesia were rare and generally < 1% for both treatments. For younger children, fever, vomiting, diarrhea, rhinitis, rash and otitis media were the only AEs with an incidence rate > 1% (in either treatment group). For older children, the only AEs with an incidence rate > 1% in either group were rhinitis, pharyngitis and otitis media. AEs were generally mild to moderate for both treatments within the two age groups. There were no serious AEs, including anaphylaxis, Reye's syndrome, renal failure, GI bleeding/perforation or necrotizing fasciitis. There was a slightly higher overall incidence of side effects in the ibuprofen group (17.6% vs. 15.0%) for the younger children; and similar results were seen in the older children (11.9% vs. 10.7%). This may have been due to the preference of physicians to treat the sicker children with ibuprofen. There were four deaths, all unrelated to study medication, all occurring in children < 2 yrs (herpes encephalitis, sepsis due to 5. pneumoniae, medulloblastoma, and sudden infant death syndrome). The safety of ibuprofen suspension in children < 2 yrs was demonstrated in this study. The safety profile in children < 2 yrs is consistent with the excellent profile observed in children [Symbol: see text] 2 yrs. Overall, ibuprofen exhibited an AE profile similar to acetaminophen in both younger and older children.
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PMID:Safety profile of ibuprofen suspension in young children. 1763 93

(1) In France, between 1985 and 2002, there were 590 reports of psychiatric adverse effects in patients receiving fluoroquinolones. These mainly included cases of confusion, hallucinations, agitation, delirium, insomnia and drowsiness. Elderly patients appear to be at greatest risk. (2) The reports implicated all available fluoroquinolones and, in most cases, oral intake. (3) Fluoroquinolone dose regimens should be reduced in cases of renal failure. The Cockcroft formula is used to derive creatinine clearance from plasma creatinine levels.
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PMID:Fluoroquinolones: psychiatric adverse effects. 1838 38

Sleep disorders are common in dialysis patients. Insomnia is reported in almost 70% of the dialysed. Old age, presence of common sleep disorders, such as sleep apnea syndrome (SAS) and restless legs syndrome (RLS), comorbid clinical conditions, metabolic parameters and characteristics of dialysis, represent the main risk factors for insomnia. RLS is independently associated with uremia, affecting almost 30% of Caucasians dialysed. Pathophysiology of uremic RLS is still unclear. Although the exact pathogenetic mechanism remains unknown, the efficacy of kidney transplantation on RLS symptoms supports the involvement of renal function in this disturbance. SAS affects 30-80% of dialysis patients. The use of neurophysiological measures is necessary to diagnose SAS. This approach is not applicable in all dialysis patients; consequently, validated questionnaires might be useful to screen patients with a high risk of apnea. Risk of obstructive and central respiratory events are increased by renal failure and dialysis therapy. Excessive daytime sleepiness (EDS) is often reported by the dialysed population. Direct effects of uremic encephalopathy and of somnogenic cytokines have been suggested as the cause of EDS, in addition to the sleep disturbances that increase daytime sleepiness by impairing nocturnal sleep efficiency. Although less frequent, the presence of other sleep disturbances (such as nightmares and narcolepsy) should be carefully evaluated in the uremic population. Several sleep disturbances may potentially be treated but, if left untreated, may impair health status and increase the risk of mortality. However, literature and personal data suggest that undertreatment is common, calling to higher awareness of sleep disturbances among nephrologists.
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PMID:Sleep disturbances in dialysis patients. 1844 35

Kidney transplantation provides the best outcome for patients with end-stage renal failure both in terms of morbidity and mortality and health-related quality of life (QoL). Health-related QoL has become recognized as an important outcome measure in patients with different chronic medical conditions, including chronic kidney disease (CKD). There are several factors in kidney-transplanted patients which have a negative impact on QoL in these patients. Sleep disorders, such as insomnia, sleep apnea syndrome (SAS), and restless legs syndrome (RLS), are common in kidney-transplanted patients and clearly belong to this group of factors, although there is only limited published data available about the association between sleep problems and QoL in this patient population. The prevalence of both insomnia and RLS is reduced in kidney-transplanted patients compared to dialysis patients, and it is similar to the prevalence observed in the general population. The prevalence of sleep apnea, however, is very high, around 30%. The association between the presence of these sleep disorders and impaired QoL has been relatively well documented in dialysis patients, but there is only scarce published information about this association in the kidney transplant population. In this paper, we will summarize data from the literature describing the impact of sleep problems, which are potentially treatable, on QoL in kidney-transplanted patients. We suggest that the appropriate diagnosis and management of sleep disorders may improve QoL in kidney-transplanted patients.
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PMID:Sleep disorders and quality of life in renal transplant recipients. 1918 10


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