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Presentation - Coggle Diagram
Presentation
Discussion
Zolpidem Evaluation
not at the level of evidence based treatments
inconclusiveness
lack of cohort or double-blind placebo-controlled studies, heterogeneity of patients characteristics, lack of properly defined exclusion and inclusion criteria, ill-defined recovery criteria, not using standardized assessment test, large number of non-responders
sporadic, accidental discoveries
Methodological aspects
?
demographic variables, outcome measures, study design
sample size, mean age, mean duration of diagnosis, study design, dose of zolpidem, outcome measures, number improved, duration of effects and adverse effects
side effects - sedation haha
dosis dependent?
predominance and heterogeneity of low level evidence
conlusions based on few, well controlled trials
communality in pathological mechnisms?
hypnotic effects on frontal cortex cs baseline cognition
inconsistent use of validated outcome measures
clinical observations, own outcome measures
selective reporting bias, overestimate effect sizes
pitfalls: heterogenous collection of studies,
heterogeneity of neurological disorders, patient populations, zolpidem regimen, outcome definitions
diazepam, specificity, timescale of the effect
Zolpidem
Trade names
non-benzo
GABA agomist, receptor subtype
sleeping pill
Behavioural Evidence
transient improvement reflecting the drugs short half-life
reproducible
LTM efficacy, no side effects, no tolerance
Neuroimaging
cerebral perfusion
Modes of Action
Reversing neurodormancy
reversal of neurodormancy only useful in VS? do mcs patients benefit?
Mesocircuit hypothesis
EEG study, dorman state
paradox: insomnia medication and arousal
proximate action - snowball effect
remarkable, but paradoxical effects
Reports vs Investigations
clinical outcome vs metabolic activity/cerbral perfusion
correlation of clinical improvments with neuroimaging observations
Issues
Trauma vs Non Trauma
cause of DoC
multifocal or global
varying and unknown pathophysiology
DoC duration vs spontaneous recovery
low rate of sp recovery anyway
pooled analysis: heterogeneity of treatments, variety of outcome measures, different stages asseses (chronic or not)
EEG replaced by alpha?
viscious circle of NT exhaustion
ineffectiveness of one dopaminergic agent does not predict effectiveness of another agent
what are prospective studies?
Intro
miracelous awakenings
media coverage
Louis Viljoen
Classes of agents, dimensions of consicousness
Outlook
Implications Future Research
further clinical trials + sound methodology
definition of recovery
Implications daily clinical practice
Other interventions
levodopa, amantadine, baclofen