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There are 80.000 patients undergoing replacement opiate programs in Spain, mainly methadone. Gender differences and the ratio of dual diagnosis in this population are unknown.
To describe gender differences in the current therapeutic management of opiate-dependent patients undergoing a replacement therapy program in Spain.
624 patients from 74 centers in Spain were included between September 2008 and February 2009 in an observational, cross-sectional, multicenter study. Patients were ≥ 18 years, had a diagnosis of opiate dependence according to DSM-IV-TR criteria, were currently scheduled in a replacement therapy program in Spain and were given written informed consent.
Only 16% of patients were female. Methadone average doses were significantly higher in man (57,59mg ± (SD 46,77) vs 52,81mg ± (SD 50,81) (p< 0.05)). Most women were caretaken by their partner (56.8% vs 34,2%) and man by their parents (61,6% vs 37,8) p< 0,05.Women were found to have significantly more sexual disorders than men (6% versus 2%; p=0.0316); but less delirium, dementia, amnesic and other cognitive disorders (none versus 6%; p=0.0486); schizophrenia and other psychotic disorders (3% versus 13%; p=0.0226); and adaptive disorders (2% versus 9%; 0.0427). No significant differences were found between sexes for other psychiatric comorbidities.
The ratio between men and women was close to 5/1, being bigger than that in the general opiate dependent Spanish population. Dual diagnosis rates vary by gender, but not in the number of diagnosis in Axis I or II. Gender differences must be considered when planning dependence services as women.
Describe the prevalence and characteristics of psychotic symptoms in the context of cocaine injection use in a harm reduction program.
To find associations between intravenous cocaine use and other drug use in cocaine dependent patients suffering from cocaine induced psychosis (CIP). Cannabis was found to be a risk factor for developing CIP in non-intravenous cocaine dependence.
During a period of 6 months professionals from our Outpatient Drug Clinic completed a confidential questionnaire to describe the adverse clinical effects following cocaine injection. It included age, gender, ethnic group, daily consumption rate and other drugs used in the last 30 days.
Survey was achieved with a sample of 75 Caucasians patients, 69 men and 6 women with an average age of 32 years old. Seventeen percent (13/75) had psychotic symptoms, of which 84% (11/13) had hallucinations (visuals 4/11, auditive 7/11 and kinaesthetic 2/11), 15% (2/13) illusions.
Eighteen percent (14/75) had stereotypy movements and 3% (2/75) had aggressive behaviour. Drugs used by CIP patients, the previous 30 days were: 61% (8/13) cannabis, 31% (4/13) opiates and 15% (2/13) alcohol.
Intravenous cocaine use produced acute psychotic symptoms in 17% of our patients, of which 61% used cannabis. Despite the ethical and practical implications of this type of study, it is necessary to do more observational studies with bigger surveys to conclude these results with statistically significance.
Oxidative stress suposses an imbalance between oxidants and antioxidants molecules. Negative and positive family environment have been related with worse and better outcomes respectively in schizophrenic patients.
Our objetive is to determine antioxidant defense in healthy controls and unaffected relatives of early onset psychosis patients and to asses its relationship with familiar environment.
We included 82 healthy controls (HC) and 14 healthy controls with second degree family history of psychosis (HCWFHP), aged between 9 to 17.
Total antioxidant status and lipid peroxidation test were determined in plasma and antioxidant enzime activities and glutathione levels were determined in erytrocytes.
We used the Global Assesment Functioning scale (GAF) and the Family Environment Scale (FES). The FES is made up of ten subscales: cohesion, expressiveness, conflict, independence, achievement, intellectual-cultural, social, moral, organization and control.
The analyses showed a significant decrease in total antioxidant level in HCWFHP compared with the HC (U Mann Withney = 281.00, p=0.009, effect size= -0.78).
HC and HCWFHP did not differ in the GAF scale, nevertheless the scores of HCWFHP were significantly higher in cohesion and intellectual-cultural dimensions of the FES (p=0.007, p=0.025).
Adjusting by this two FES dimensions, antioxidant status remained significantly different between groups: OR= 10.86, p=0.009.
Although we cannot induce causative relations, we can state that family environment is not playing a role in inducing oxidative stress in these subjects. It could be hypothesized that families with affected relatives protect themselves with positive envionmental factors such as cohesion and intellectual-cultural activities.
Adult attention deficit hyperactivity disorder (ADHD) has a prevalence up to 4% of the general adult population, however in Spain adult ADHD is underdiagnosed. Screening instruments can help clinicians to detect adult ADHD. The World Health Organization Adult ADHD Self-Report Scale-Version 1.1 (ASRS v1.1) is a 6-question scale designed to screen for adult ADHD.
A validation of Spanish version of the ASRS v1.1 was performed.
A case control study was carry out (adult ADHD vs non ADHD) in the Adult ADHD Program of the Hospital Universitari Vall d'Hebron (Barcelona). ADHD evaluation was performed using Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID-Part II) and the diagnosis was compared with the ASRS v1.1 responses. Logistic regression study was made to evaluate the sensitivity, specificity, positive and negative predictive values (PPV and NPV). Kappa coefficient of classification accuracy and area under curve (AUC) were calculated.
Sample consisted of 90 adult ADHD and 90 controls. Average age was 31.6 (SD=10.09) and 57.8% of subjects were men (there were no significant differences between the two groups). Logistic regression analysis showed that the score model proposed by the authors of scale is significant (c2 =129.36, p=.0005): Sensitivity (82.2%), specificity (95.6%), PPV (94.8%), NPV (84.3%), Kappa coefficient 0.78 and AUC 0.89.
The Spanish version of the ASRS v1.1 6-question shows adequate psychometric characteristics and it is a valid scale to screen ADHD for adults in a clinical setting.
The high prevalence of those called “revolving-door patients” continue supposing a high sanitary cost. The aim of this study was to identify factors associated with multiple admissions in a psychiatric unit.
The sample included all patients hospitalized in a psychiatric unit at the hospital “Virgen de las Nieves” in the city of Granada (southern Spain), during the time period between 1998 and 2006 (n=1873). There is no consensus in the literature with regard to the definition of the “revolving-door phenomenon”. Basing on prior studies (Woogh, 1990; Thornicroft et al., 1992), we defined "revolving-door patients” as those who had been hospitalized eight or more times in an eight-year period (an average of at least an admission per year).
The prevalence of revolving-door patients was 10% (186/1873). The condition of revolving-door patients was associated with male sex (OR=1.5; IC 95%: 1.1-2.1), with a marital status different from the married one (OR=1.8; IC 95%: 1.3-2.6), and with the diagnoses of schizophrenia (OR=3.3; IC 95%: 2.4-4.6), schizoaffective disorder (OR=3.8; IC 95%: 2.3-6.5), bipolar disorder (OR=2.1; IC 95%: 1.4-3.2) and personality disorder (OR=2.2; IC 95%: 1.3-3.5).
Male sex, marital status different from the married one and the diagnoses of schizoaffective disorder or schizophrenia may be a risk factor of readmission in a psychiatric unit. A better comprehension about the characteristics of these patients may help to establish more effective strategies to board the psychiatric community.
We aimed to study the relationship between impulsivity and the addiction severity in 3 groups of outpatients attending our clinic, through the Barrat Impulsivity Scale (BIS-11) and the standarized, semistructured interview EuropAsi.
174 outpatients were analized (82.6% men, 113 cocaine-dependent as main drug (mean age 32.71 y.o. (31.45–33.96)), 43 cocaine and heroin-dependent (mean age 36.68 y.o. (33.52–39.85)) and 18 heroin dependent (mean age 37.94 (32.71–41.50)). 26.3% were cannabis-dependent and 10.9% abused of Cannabis. Statistical analysis used was the Kruskal-Wallis Test.
Differences in motor impulsivity were found between the 2 groups with cocaine dependency and the only heroin-dependent (mean = 20.59, ST ± 7.7 and mean = 17.11, ST ± 7.3, respectively; W: .019). EuropASI, showed intergroup differences in the medical, use of alcohol and legal areas. In the medical area the most affected were the heroin dependent group (mean score = .40), followed by cocaine and heroin group (mean score = .27) and the cocaine-dependent (Mean = .10). In the use of alcohol area the most affected were the cocaine group (Mean = .16) followed by the cocaine and heroin-dependent (mean = .11) and heroin dependent (Mean = .06). In the legal area the most affected were the the cocaine and heroin-dependent (Mean =.22) followed by heroin-dependent (Mean = .09) and cocaine-dependent (Mean = .07).
Patients suffering from stimulant dependency alone or together with heroin dependency show different impulsivity levels. The addiction severity varies depending on the substance of abuse. Treatment programs should be designed attending patients’ needs.
To describe validation process of the new apathy scale for institutionalized dementia patients (APADEM-NH).
100 elderly, institutionalized patients with diagnosis of probable Alzheimer Disease (AD) (57%), possible AD (13%), AD with cerebral vascular disease (CVD) (17%), Lewy Bodies Dementia (11%) and Parkinson associated to dementia (PDD) (2%). All stages of the disease severity according to the Global Deterioration Scale (GDS) and Clinical Dementia Rating (CDR) were assessed. The Apathy Inventory (AI), Neuropsychiatric Inventory (NPI), Cornell scale for depression, and the tested scale were applied. Re-test and inter-rater reliability was carried out in 50 patients. The feasibility and acceptability, reliability, validity, and measurement precision were analyzed.
APADEM-NH final version consists of 26 items and 3 dimensions: Deficit of Thinking and Self-Generated behaviors (DT): 13 items, Emotional Blunting (EB): 7 items, and Cognitive Inertia (CI): 6 items. Mean application time was 9.56 minutes and 74% of applications were fully computable. All subscales showed floor and ceiling effect lower than 15%. Internal consistency was excellent for each dimension (Cronbach’s α DT = 0.88, α EB = 0.83, α CI= 0.88);Test-retest reliability for the items was kW=0,48-0,92; Inter-rater reliability reached kW values 0.84-1.00; The APADEM-NH total score showed a low/moderate correlation with apathy scales (Spearman ρ, AI =0.33; NPI-Apathy= 0,31), no correlation with depression scales (NPI-Dementia = -0.003; Cornell= 0,10), and high internal validity (ρ =0.69 0.80).
APADEM-NH is a brief, psychometrically acceptable, and valid scale to assess apathy in patients from mild to severe dementia and discerning between apathy and depression.
Attention Deficit Hyperactivity Disorder (ADHD)presents high levels of life-long comorbidity. Several studies demonstrate an elevated coocurrence between ADHD and Substance Use Disorder (SUD) as well as personality disorders.
The objective of this poster is to demonstrate differential characteristics between ADHD with SUD patients versus ADHD without SUD, in relation to Axis II comorbidity, ADHD symptoms severity and childhood behavioural disorders (conduct disorder and oppositional defiant disorder).
Another objective is to identify differences in the prevalence of SUD relative to gender and ADHD subtype (Inattentive, Hyperactive/Impulsive and Combined).
This will be done using a comparative-descriptive study that was carried out with a sample of 125 adults diagnosed with ADHD using the CAADID in the Adult ADHD Integral Programme (PIDAA) of Vall d'Hebron Universitari Hospital; 53 subjects presented associated SUD (DSM-IV). All the subjects were evaluated with ADHD Rating Scale, SCID-I, SCID-II and K-SADS.
Relative to ADHD group, subjects ADHD with SUD subjects showed higher comorbidity with Axis–II Disorders, especially with antisocial, schizoid and paranoid personality disorders, as well as major prevalence of conductual disorder and oppositional defiant disorder in childhood. There were no significant differences respect to ADHD symptoms severity nor ADHD subtype between both groups. A major proportion of men were observed in ADHD with SUD group compared to ADHD patients.
Antipsychotic therapy is the cornerstone of the treatment of schizophrenia and other psychoses. Although clinical guidelines tend to recommend the use of antipsychotics in monotherapy, combination of two or more antipsychotics (that is, polytherapy) is a common habit in clinical practice.
To assess differences in antipsychotic combination profile between patients with schizophrenia and patients with other psychoses.
A total of 241 patients (40.2% females, mean age 39.7+/−13.0 years) consecutively admitted during 2009 to a psychiatric inpatient ward with diagnosis of schizophrenia and other psychoses were assessed.
145 (60.2%) patients were diagnosed with schizophrenia while 96 patients (39.8%) were diagnosed with other psychoses (schizoaffective disorder n = 35, delusional disorder n = 8, schizophreniform disorder n = 8, brief psychotic disorder n = 13, psychotic disorder not otherwise specified n = 27, and other psychoses n = 5). Out of the total sample, polytherapy was used in 150 (62.2%) patients. A total of 100 (69.0%) patients with schizophrenia were on polytherapy, compared to 52.1% of those with other psychoses (p = 0.008). After controlling for age and gender, the association between a diagnosis of schizophrenia and being in polytherapy remained significant (p = 0.046).
Patients diagnosed with schizophrenia are more prone to be in polytherapy than those with other psychoses.
At least one-half of patients in substance use treatment have been diagnosed with comorbid psychiatric disorders. High prevalence of severe mental disorders co-occurring with substance use have been described. Harm reduction refers to policies, programs and practices that aim to reduce the harms associated with the use of illegal drugs in people unable or unwilling to stop.
To describe attendance and integration of patients with substance use disorders in a harm reduction program, to psychiatric treatment.
Find the importance and profitability of Harm Reduction Programs as an access door to psychiatric treatment in people with drug addiction.
Data was gathered from the first interview survey made to patients that contacted the Harm Reduction Program or attending the Outpatient Drug Clinic Vall d’Hebron in Barcelona between January 2005 until September 2010.
A total of 348 patients (males = 71%, European community origin = 92%, mean age = 28,18 years). 63,8% of patients were under medical and psychiatric treatments, 55,4% attended the Methadone Maintenance Program, 7,4% other psychiatric treatments, and other treatments without specification 30,7%. The residential status was: 38% squatters, homeless 9,7%, hostel 3,4%, home 43%, lodging 2%, others 3%.
More than fifty percent of harm reduction program patient's were in a psychiatric treatment, it is an advantage that in the outpatient drug clinic of Vall d’Hebron both programs are included: harm reduction and psychiatric assessment. Access to integral treatment is important for people with drug problems, but many people with drug problems are unable or unwilling to get treatments.
Polyfarmacy is frequent in patients with dual diagnosis.
To quantify the number and describe the treatments prescribed in a cohort of outpatients with dual diagnosis.
Material and methods
A descriptive and transversal study was performed. Patients with dual diagnosis treated at an Outpatient Drug Treatment Center from January 2005 to December 2009 were included. Data from demographic, clinical and therapeutical variables were gathered once. The instruments used for the diagnosis were EuropASI y SCID-I. The number and type of prescript drugs were related with protocol variables.
The study sample included 80 patients (71,6% men, average age 37,2 ± 9). Psychotic disorders (46.8%) and cocaine dependence/abuse (34.6%) were the most frequent comorbid psychiatric illnesses found. 40.8% of patients were polydrug users. The mean of prescript drugs was 3,06 ± 1,4 and only 14% of patients were on monotherapy. The frequency of drugs prescribed was: 68,4% antidepressant, 63,3% antipsychotic, 55,7% antiepileptic and 36,7% anxiolytic drugs. Older patients ( > 45years) took a major number of prescripted drugs (3,88 ± 1,1). Patients with psychotic disorders took the 43.9% of drugs prescripted (p = 0,042). Patients with benzodiazepine abuse took higher number of prescription drugs (5 ± 1,4;p = 0,003) compared with patients with other dependence or abuse.
Patients with dual diagnosis take high quantity of drugs. Older patients, diagnosis of psychosis and benzodiacepine abuse were related with polydrug prescription. Quantification of medication is recommended for treatment optimisation and avoiding yatrogenic.
Chronic consumption of cocaine can induce transient psychotic symptoms, expressed as paranoia or hallucinations. This is typically prevented by abstinence. The term Cocaine-Induced Psychosis (CIP) has been used to describe this syndrome. Impulsivity has been hypothesised are likked with CIP.
This study examined the relationship between CIP and substance consumption variables and impulsivity disorders including ADHD (Axis I) and Borderline personality disorders (BPD) (Axis II), and attempted to evaluated their link as a risk factors for CIP.
Trained psychiatrists systematically conducted a structured interview in which the conclusions from the psychotic symptoms were summarized. We used the CADDID to evaluate Adult ADHD, SCID II for axis II disorders, and the Barrat Impulsivity Scale (BIS-11).
We evaluated 163 (34,16 yo, 85,80% men) cocaine-dependent patients, according to DSM-IV criteria.
We found statistically significant association between CIP and Early age at onset of cocaine addiction (p = 0,04), cocaine use per day 6 months before starting treatment (p = 0,03), Barrat cognitive impulsivity subscale (p < 0,004), and Adult ADHD (p < 0,041). No relationship between BPD and CIP was found.
We confirm previous findings that Impulsivity disorders as ADHD or high impulsivity trails are liked to CIP. Coinciding with our previous findings, relationship between early age of onset cocaine dependence or high amounts of cocaine use and CIP was found. CIP are related with impulsivity disorders spectrum.
To determinate the prevalence of several mental disorders and its relationship with sex among patients admitted in a Psychiatric Unit.
The sample included all patients hospitalized in a Psychiatric Unit at the Hospital “Virgen de las Nieves” in the city of Granada (southern Spain), during the time period between 1998 and 2006 (n=1873). The tenth version of international classification diseases (ICD-10) was used to classify the mental disorders.
The principal diagnoses were psychotic disorders (36%), affective disorders (30%), substance-related disorder (8%) and personality disorder (7%). The prevalence of men was 57% and the prevalence of women was 43%. Male sex was significantly associated with substance-related disorder (OR=3.2; IC 95 %: 2.1-4.9), schizophrenia (OR=3.7; IC 95 %: 2.7-4.9) and mental retardation (OR=1.2; IC 95 %: 2.4-4.0). Female sex was significantly associated with bipolar disorder (OR=1.7; IC 95 %: 1.3-2.3), dysthymia and other depressive disorders (OR=2.4; IC 95 %: 1.9-3.1) and neurotic disorders (OR=2.3; IC 95 %: 1.4-3.7).
According with literature (Vogel et al, 1997) the principal diagnoses among patients hospitalized were psychotic disorders, followed by affective disorders. Previous epidemiological studies have shown similar prevalence of bipolar disorder among both sexes (Kessler et al, 1997; Kawa et al, 2005). Nevertheless, among patients with bipolar disorder who need hospitalization may be more women.
Disturbed eating behaviors are a significant health concern among child and adolescents with type 1 diabetes mellitus (DM1) and are generally related to poor glycemic control, ketoacidosis, hospitalization and microvascular complications. Rates of eating problems among youths with DM1 have been reported to be as high as 38%.
To review clinical characteristics, demographic profiles and risk factors for the development of eating disturbances among child and adolescents with DM1.
We performed a literature research of articles from 1980 until present, in which a Disturbed Eating Behavior appeared comorbid with DM1 in children and adolescents, using Medline database.
Almost all studies selected report a high prevalence of eating disturbances of child and adolescents with DM1 when compared with healthy pairs. This population trend to develop body image discontent and lower self-esteem. They are more likely to diet, skip meals, and omit insulin. All these practices have been associated with worsening diabetic medical complications and poorer psychological outcome.
Due to the high prevalence and severe medical and psychological complications associated with disturbed eating behaviors among pediatric population with DM1, clinicians and school professionals may benefit from specialized training to identify the range of unhealthy weight control behaviors used by youths with DM1. Preventive programs that address disturbed eating behaviors should be provided for adolescents with DM1 in order to reduce the psychological and medical impact of this comorbid situation.
The aim of this study was to measure the reliability, validity, and classification accuracy of a Spanish translation of a measure of DSM-IV diagnostic criteria for Pathological Gambling. Participants were 263 male and 23 female patients seeking treatment for pathological gambling and a matched non-psychiatric control sample of 259 men and 24 women. A Spanish translation of a 19-item measure of DSM-IV diagnostic criteria for Pathological Gambling was administered along with other validity measures. The DSM-IV diagnostic criteria were found to be reliable with an internal consistency coefficient alpha of .95 in the combined sample. Evidence of satisfactory convergent validity included moderate to high correlations with other measures of problem gambling. Using the standard DSM-IV cut-score of five, the ten criteria were found to yield satisfactory classification accuracy results with a high hit rate (.95), high sensitivity (.92), high specificity (.99), low false positive (.01), and low false negative rate (.08). Lowering the cut score to four resulted in modest improvements in classification accuracy and reduced the false negative rate from .08 to .05. The Spanish translation of a measure of DSM-IV diagnostic criteria for Pathological Gambling demonstrated satisfactory psychometric properties and a cut score of four improved diagnostic precision.
In 2009, Joan Y. Chiao, one of the leading experts in Cultural Neuroscience, labeled the research field as „a once and future discipline”. Ten years ago neuroscientists began to study cultural phenomena applying functional Magnetic Resonance Imaging (fMRI). Since then the number of publications and research grants related to this topic has tremendously increased. This was reason enough to examine the concepts of culture implicated, but rarely explicitly discussed, in these studies. Therefore we analyzed 42 English language manuscripts of original fMRI studies spanning from the advent of Cultural Neuroscience in the year 2000 to 2010 published in peer-reviewed journals (indexed in large databases [MEDLINE, PsychInfo, PubMed). Common to all of them were cultural comparisons between divided groups and communities, as e.g. black vs. white, easterners vs. westerners, Asian vs. Caucasian, Americans vs. Turks.
We reviewed the manuscripts with regard to the following aspects: type of comparison, the conveyed concept of culture using the classification by Reckwitz [normative, totality-oriented, differentiation-theoretical and the meaning- and knowledge-oriented], implicit valuation of the comparisons, and the artifact of the comparison. We extracted two main lines of reasoning:
1) Universal models for the interaction between cultures and
2) investigations pursuing a differentiation of divided cultural groups.
Both lines tend to simplify culture as an inflexible set of traits, specificities or biological diversities. We argue against the rigid understanding of culture, point out its disguised valuation and risks considering the Hackingian ‘looping effect’.
Childhood or Early Onset Schizophrenia (EOS), defined as the onset of psychotic symptoms before the thirteenth birthday, represents a rare, clinically severe variant, associated with significant chronic functional impairment and poor response to antipsychotic treatment. Despite of that, in clinical practice, atypical agents have become the treatment of choice in patients with EOS.
To review the different pharmacological strategies, in which an atypical antipsychotic was used in the management of EOS in childhood and adolescence.
We conducted a literature search of articles related to the use of atypical antipsychotics in children and adolescents with EOS in the last 20 years from the Medline database.
Several atypical antipsychotics, such as Risperidone, Olanzapine, Quetiapine, Aripiprazol and Clozapine were consistently found to reduce the severity of psychotic symptoms in EOS when compared to placebo. Although Clozapine has demonstrated to be more efficacious than other atypical and typical antipsychotics, it remains the medication of last resort due to its profile of side effects. Finally, in general, children and adolescent have a higher risk of extrapyramidal symptoms, akathisia, prolactin elevation, sedation and metabolic effects of atypical antipsychotics than adults.
Antipsychotics are the mainstay of treatment of EOS. Randomized controlled trials suggest a trend to superior efficacy for atypical antipsychotics over classic antipsychotic. Children and adolescents trend to be more sensible to antipsychotic side effects. Clinicians should be aware of this problem and be careful when monitoring this type of treatment.
Atypical antipsychotic use in youth has increased. Adverse metabolic effects on weight, lipids, and glucose are evident in adults, but inadequately studied in youth. This report focuses on the metabolic effects of these agents in psychiatrically hospitalized youth.
Inpatient subjects were assessed at admission, 3 weeks, and discharge. Weight, body mass index, blood pressure, fasting glucose levels, high and low density lipoproteins (HDL and LDL, respectively), and triglycerides were measured.
N=112 subjects, diagnosed as: Affective Disorders (26.4%), Disruptive Behavior Disorders (32.6%), Pervasive Development Disorders (9.3%), Psychotic Disorders (5.4%), and Others (26.3%). Ages ranged from 4-17 years. Patients received: risperidone (N=41), olanzapine (N=13), quetiapine (N= 15), aripiprazole (N=22), while 34 patients received no medication. Average length of hospital stay (LOS) was 55.9 days (1-289). For the sample as a whole, trends of statistical differences were noted in weight at the time of discharge (+3.79 lbs). Weight gain at discharge was significantly correlated with only olanzapine (r=.553, p<0.0001), multiple regression analysis controlling for LOS is also significant (Beta .558, p < 0.0001) for olanzapine. For the medication treated group, statistically significant increases in HDL are noted at three weeks (+ 5 mgs/dl, p = 0.023); at discharge the difference was not significant. A similar trend was observed for glucose. There was a statistical trend for decrease in triglycerides at 3 weeks (15 mg/dl, p = 0.054), discharge difference was non-significant (-9 mg/dl).
Certain agents may carry greater propensity for inducing certain metabolic changes, but further study is required.