Pharmacology
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Browsing Pharmacology by Author "Gagiano, C. A."
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Item Open Access Hypothalamic-pituitary-adrenal axis function and hypothalamic-pituitary-thyroid axis function in mentally retarded oatients with and without self-injurious and/or aggressive behaviour(University of the Free State, 2003-12) Van Zyl, Paulina Maria; Gagiano, C. A.; Walubo, A.; Bester, C. J.English: The etiology of aggression and self-injuring behaviour in low functioning mentally retarded patients is multi-factorial and may reflect the presence of undiagnosed psychiatric conditions, unapparent due to the degree of the patient's impairment. It may also reflect hyperactivity of the stress response. The intricacies of diagnosis in this group of patients call for the development of biological markers to aid in diagnosis, therapy selection and drug response monitoring. Measuring and determining the relative contribution of individual neurotransmitters in the problem behaviour is complex and impractical. An alternative route may be to evaluate the functions of the hypothalamic-pituitary axis, which has extensive connections with the limbic area and is relatively easy to assess. The hypothalamic-pituitary system controls the behavioural, endocrine, autonomic and immunological responses to stress. The dexamethasone suppression test (OST) as adapted by Carroll and the thyroid-releasing hormone stimulation test (TRHST) has been extensively used in research on biological markers in major depression. Stress is known to activate the hypothalamic-pituitary-adrenal (HPA) axis, reflected by elevated cortisol levels. The study is a matched control study comparing hypothalamic-pituitary-adrenal axis function and hypothalamic-pituitary-thyroid axis function in 44 institutionalised mentally retarded patients with and without self-injuring and aggressive behaviour through the measurement of baseline cortisol levels and the application of the dexamethasone suppression test and the thyroid-releasing hormone stimulation test. The groups were matched according to gender, age and level of functioning. The mean age of the aggressive group 106 was 44,1 years (±SO 9,8) and the mean age of the non-aggressive group was 44,2 years (±SO 10,5). Baseline hypercortisolaemia occurred in five of the 22 aggressive subjects (22,7 %) and in two of the 22 non-aggressive subjects (9,1 %). Cortisol nonsuppression with the OST occurred in two subjects in the aggressive group (9,1 %) and one subject in the non-aggressive group (4,5 %). The OST did not demonstrate a difference in the two groups, yet there were more individuals in the aggressive group with abnormal high baseline cortisol, as well as a tendency towards a higher baseline cortisol in the aggressive group, suggesting an abnormal or more reactive stress response. Higher baseline cortisol levels were not related to age or the type of aggression, yet subjects with more recent aggressive activity showed higher baseline cortisol levels. The TRHST was generally well tolerated by the subjects. Side effects were few and transient. There were two male subjects in the aggressive group showing a blunted TRHST. Primary hypothyroidism was demonstrated in one of the female subjects in the non-aggressive group and subclinical hypothyroidism in two subjects in the non-aggressive group, as well as in one subject in the aggressive group. Longitudinal studies are needed to determine cortisol levels in unmedicated patients, in addition to comparing cortisol levels during different kinds of treatment.Item Open Access An integrated framework for the treatment of substance addiction and dependency in the Free State(University of the Free State, 2009-11) Van Zyl, Paulina Maria; Gagiano, C. A.; Mollentze, W.; Snyman, J.; Joubert, G.English:Background: Historically characterized by a high prevalence of alcohol addiction and dependency, South Africa has in recent years experienced an unprecedented increase in illicit drug use, linked to organized criminal activities. While internationally, the role of pharmacotherapy in the multi-disciplinary treatment of addiction/dependency becomes more important based on an increasing body of evidence revealing the biological nature of the condition, major transformation in the Health and Social delivery systems are taking place locally. Aim: The study aims to provide a critical analysis of current treatment practices regarding pharmacotherapy for drug addiction/dependency in the Free State against the background of the biological processes involved in the addiction/dependency state as well as aspects of health service delivery that may influence the use of pharmacotherapy. The analysis forms the basis for the development of a framework for the treatment of substance addiction and dependence regarding pharmacotherapy, taking into account the findings of the literature study and local context. Material and Methods: Both quantitative and qualitative methods were used. A questionnaire and structured interview were conducted with 121 health care professionals that could reasonably be expected to be confronted by patients with addiction and dependency. The population included a randomized sample of general practitioners selected from regional, district and basic environments in the Free State; purposely selected representatives of state hospitals and private treatment centres, as well as private psychiatrists and therapists in the corresponding towns. Results: Help-seeking for addiction occurs in a distinguishable pattern across the various professional groups. Private general medical practitioners are an important conduit into treatment for alcohol addiction and dependency. Depending on the local organization of services, they are also actively involved in the medical treatment of addiction and dependency cases. Private psychiatrists exclusively deal with dual diagnosis patients and are exposed to a wider range of addiction/dependency cases. State hospital service delivery varies from comprehensive services to no services. Perceptions regarding access to state hospitals and the quality of services in state hospitals are poor, while private services are generally regarded as costly, yet effective. Medical Scheme policies play an important role in determining access to facilities and services and dictate the individual prescriber‟s approach to pharmacotherapy. Respondents regarded the role of pharmacotherapy as essential in withdrawal and neuropsychological support, yet less important in relapse prevention. Convention mainly determines the withdrawal regimens used by respondents, with a number of area-dependent exceptions. Recognition of the neurotoxic nature of the withdrawal state is not universally reflected in the selection of pharmacotherapeutic agents in withdrawal regimens. Only disulfiram is commonly used for relapse prevention and its use is limited by high cost. Besides financial status, the decision to prescribe these drugs is based on the patient‟s motivation or willpower. Conclusion: A basic lack of recognition of the biological basis of addiction and dependency exists in the current legislation, in the organization of services and in the management of addiction/dependency. Medical intervention in addiction/dependency typically occurs late and follows an intermittent course with short-term goals. Recommendations: An integrated framework was developed and needs to be considered for implementation at both organizational and treatment practice levels in the region with the primary objective to improve treatment outcomes. Rational prescribing of pharmacotherapy requires an expansion of medication options and improved screening methods to allow individualized treatment, a biological imperative for successful treatment. At the same time standardization of evidence-based best treatment practices should be implemented. The role of private general practitioners as primary gatekeepers of the health system should be restored to provide a platform for accessible medical treatment of addiction and dependency.