Cognitive effects of lamotrigine compared with topiramate in patients with epilepsy

OBJECTIVE

To compare the cognitive effects of lamotrigine vs topiramate as adjunctive therapy in adults with epilepsy.

METHODS

A multicenter, double-blind, randomized, prospective study was conducted in adults with partial seizures. Lamotrigine or topiramate was introduced as an adjunctive therapy to carbamazepine or phenytoin and titrated over 8 weeks to target doses. These drugs were maintained another 8 weeks (maintenance phase) without dosage changes. The primary endpoint was change from screening to the end of the maintenance phase in a combined analysis of standardized measures of cognition (Controlled Oral Word Association Task [COWA]; Stroop Color-Word Interference; Digit Cancellation; Lafayette Grooved Pegboard, dominant hand; Rey Auditory Verbal Learning Test, delayed recall; and Symbol-Digit Modalities test).

RESULTS

For the primary endpoint, cognitive performance at the end of the maintenance phase was better with lamotrigine than with topiramate (415.3 vs 315.1; p < 0.001). On the individual cognitive tests, performance was better with lamotrigine than with topiramate in mean changes from screening on the COWA (p < 0.001), Stroop Color-Word Interference (p = 0.038), and Symbol-Digit Modalities tests (p < 0.001). The treatment effect exceeded the minimum clinically important difference for the COWA and the Symbol-Digit Modalities test. Mean changes from screening in the Performance-On-Line test simulating driving skills reflected better performance with lamotrigine than with topiramate (p = 0.021). The median percentage change from baseline in seizure frequency was lower with lamotrigine than with topiramate during the escalation phase (-80% vs -100%; p = 0.028) but not during the maintenance phase (-75% vs -100%; p = 0.062). The frequencies of cognitive adverse events and of premature withdrawals related to cognitive decline were higher with topiramate than with lamotrigine (6% vs 0%; p = 0.013).

CONCLUSION

Lamotrigine had significantly less impact than topiramate on measures of cognition when used as adjunctive therapy for partial seizures.

Genetic selection of sox1GFP-expressing neural precursors removes residual tumorigenic pluripotent stem cells and attenuates tumor formation after transplantation

Because of their ability to proliferate and to differentiate into diverse cell types, embryonic stem (ES) cells are a potential source of cells for transplantation therapy of various diseases, including Parkinson's disease. A critical issue for this potential therapy is the elimination of undifferentiated cells that, even in low numbers, could result in teratoma formation in the host brain. We hypothesize that an efficient solution would consist of purifying the desired cell types, such as neural precursors, prior to transplantation. To test this hypothesis, we differentiated sox1-green fluorescent protein (GFP) knock-in ES cells in vitro, purified neural precursor cells by fluorescence-activated cell sorting (FACS), and characterized the purified cells in vitro as well as in vivo. Immunocytofluorescence and RT-PCR analyses showed that this genetic purification procedure efficiently removed undifferentiated pluripotent stem cells. Furthermore, when differentiated into mature neurons in vitro, the purified GFP+ cell population generated enriched neuronal populations, whereas the GFP- population generated much fewer neurons. When treated with dopaminergic inducing signals such as sonic hedgehog (SHH) and fibroblast growth factor-8 (FGF8), FACS-purified neural precursor cells responded to these molecules and generated dopaminergic neurons as well as other neural subtypes. When transplanted, the GFP+ cell population generated well contained grafts containing dopaminergic neurons, whereas the GFP- population generated significantly larger grafts (about 20-fold) and frequent tumor-related deaths in the transplanted animals. Taken together, our results demonstrate that genetic purification of neural precursor cells using FACS isolation can effectively remove unwanted proliferating cell types and avoid tumor formation after transplantation.

Targeting bladder tumor cells in vivo and in the urine by a peptide identified using phage display

10071

Background: Bladder cancer is one of the most common tumors of genitourinary tract. Selective delivery of drugs to tumor tissues is important for effective tumor therapy. Here we identified a peptide targeting bladder tumor cells using phage display. Methods: Phage peptide library containing CX7C (C-cysteine and X-any amino acid residue) was based on T7 415–1b phage vector (Novagen). Tumor xenografts were prepared by subcutaneously injecting BALB/c Nu/nu female nude mice with HT-1376 bladder tumor cells. For a carcinogen-induced tumor model, Fischer 344 female rats were supplied ad libitum with tap water containing 0.05% N-butyl-N-(4-hydroxybutyl) nitrosamine (BBN) for 8 weeks. Results: A phage library containing CX7C random peptides was screened for selective binding to cells from human bladder tumor xenografts. Selected phage clones were individually evaluated for binding to cultured bladder tumor cells and for binding to cells from human tumor tissues of six patients. The peptide displayed by the most promising clone was synthesized and designated as Bld-1. Fluorescein-conjugated Bld-1 peptide showed selective binding to frozen sections of human bladder tumor tissues of three patients. In vivo tumor targeting was examined in a carcinogen-induced rat tumor model (n=20). When the fluorescent peptide was introduced into the bladder lumen, it selectively bound to tumor epithelium. Next, when the fluorescent peptide was intravenously injected into the tail vein, it homed to the bladder tumor, but was not detectable in normal bladder and control organs such as lung. Moreover, the fluorescent peptide bound to cells from urinary specimens of tumor patients (n=10), whereas little binding was observed in cells from healthy individuals (n=3). Conclusions: The Bld-1 peptide may be useful for targeting bladder tumor cells in vivo and in the urine.

No significant financial relationships to disclose.

Endoscopy-assisted ultrasonic surgical aspiration of axillary osmidrosis: a retrospective review of 896 consecutive patients from 1998 to 2004

Axillary osmidrosis is a distressing and troublesome problem that causes a serious handicap in personal and social life. Many different methods have been introduced to treat axillary osmidrosis, however, they are often accompanied by marked complications. We analysed our experiences using endoscopy-assisted ultrasonic surgical aspiration in treating the axillary osmidrosis. From June 1998 to February 2004, a total of 896 patients (562 females, 334 males) were treated for axillary osmidrosis using endoscopy-assisted ultrasonic surgical aspiration. Our method was satisfactory in 815 patients (91%) and recurrence of odour occurred only in 29 (3.2%) patients. It also showed complications in 28 (3.1%) patients. Our method leaves a small inconspicuous scar and no contracture of the axillary skin after a short and comfortable recovery period and maintains normal axillary hair growth patterns. Axillary osmidrosis can be best treated by endoscopy-assisted ultrasonic surgical aspiration and this operation has many advantages with a high success rate, a low complication rate, and a rapid recovery period.

Hospital planning for acts of terrorism and other public health emergencies involving children

In today's world the increased potential of terrorist attacks places unique burdens and consequences on health care workers. Hospitals and hospital personnel must now be prepared to react immediately to such events. They must also implement, in advance, policies to protect their own health care personnel while providing care to victims. In this review, we discuss the four major forms of mass casualty terrorism (biological, chemical, nuclear, and thermomechanical) including clinical signs and symptoms for each, the impact on health care personnel, and special considerations for children. We will then outline key principles of hospital preparation with regard to paediatrics in anticipation of such emergencies.

Widespread endoscopic mucosal resection of the esophagus with strategies for stricture prevention: a preclinical study

BACKGROUND AND STUDY AIMS

Circumferential endoscopic mucosal resection of the esophagus is complicated by stricture formation. Prophylactic measures for avoiding such strictures have not been well studied. The aim of this preclinical study was to assess strategies for prevention of esophageal strictures in a porcine model following widespread endoscopic mucosal resection (EMR).

METHODS

A total of 18 60-kg pigs were included in the study. The roles of strip width (group 1), prophylactic steroids (group 2), and prophylactic stents (group 3) in the prevention of post-mucosectomy strictures were studied. Six animals were included in each group. Esophageal mucosal resection was achieved using a novel widespread EMR technique previously described by our group. Animals in group 1 underwent partial (50% circumference) mucosal resection without prophylactic measures, while animals in the other two groups underwent circumferential mucosal resection. Animals in group 2 received 80 mg of triamcinolone injected directly into the exposed submucosal tissue (20 mg injection in four quadrants). Animals in group 3 received esophageal metal stents coated with small-intestine submucosa (SIS) that were deployed immediately post-resection. Animals were kept alive for 1 month.

RESULTS

Partial and circumferential widespread EMRs were achieved in all animals. There were no procedural complications. Repeat endoscopy at 1 month showed no strictures in group 1. Only four animals were studied in group 2, owing to the high complication rate (periesophageal abscess in all animals) with one early death. Three of the surviving animals developed mild to tight strictures. In group 3, all animals developed tight strictures; however, there was early stent migration in four animals and premature stent removal in two animals because of persistent vomiting.

CONCLUSIONS

Partial widespread EMR of the esophagus heals without stricture formation and does not require prophylactic intervention. The use of deep mural steroid injection following a circumferential resection does not appear to prevent strictures and may result in serious adverse events. Short-term use of esophageal stents is inadequate for stricture prevention. However, better results may be anticipated with longer term (at least 6 weeks) stent use.

Isolation and characterization of CO2-fixing hydrogen-oxidizing marine bacteria

A CO2-fixing bacterium, strain YN-1, that can fix CO2 under chemoautotrophic conditions but not photoautotrophic conditions was isolated from seawater. Identification of the isolate was carried out using biochemical tests and 16S rDNA sequence analysis, and its characteristics were investigated. From the results of partial 16S rDNA sequence analysis, strain YN-1 showed low identity with previously reported hydrogen-oxidizing bacteria, Hydrogenovibrio marinus MH-110 and Hydrogenophilus thermoluteolus. This result indicates that strain YN-1 may be a new hydrogen-oxidizing marine bacterium. Strain YN-1 showed considerable CO2 fixation ability during continuous cultivation even at high CO2 concentration. Strain YN-1 used H2 and CO2 as energy and carbon sources, respectively. Growth characteristics were examined in batch and continuous cultivation with a view to improving the CO2 fixation rate. The results showed that CO2 fixation occurred in the absence of a light source and that the strain exhibited good growth at high CO2 concentration (40%). On the other hand, the dry cell weight was 13.4 g/l following continuous cultivation for 76 h in 10% CO2 (0.1 l/min), and at that time the amount of fixed CO2 was 18.08 g CO2/l. This indicates that strain YN-1 can efficiently fix CO2 even at high CO2 concentrations, which would allow its application to the removal of industrially discharged CO2.

The homeodomain transcription factor Pitx3 facilitates differentiation of mouse embryonic stem cells into AHD2-expressing dopaminergic neurons

The A9 dopaminergic (DA) neuronal group projecting to the dorsal striatum is the most vulnerable in Parkinson's disease (PD). We genetically engineered mouse embryonic stem (ES) cells to express the transcription factors Nurr1 or Pitx3. After in vitro differentiation of Pitx3-expressing ES cells, the proportion of DA neurons expressing aldehyde dehydrogenase 2 (AHD2) increased, while the total number of DA neurons remained the same. The highest levels of AHD2 expression were observed in mouse A9 DA neurons projecting to the dorsal striatum. Furthermore, real-time PCR analyses of in vitro differentiated Pitx3-expressing ES cells revealed that genes highly expressed in A9 DA neurons were up-regulated. When transplanted into the mouse striatum, Pitx3-expressing cells generated an increased proportion of AHD2-expressing DA neurons. Contrastingly, in Nurr1-expressing ES cells, increases of all midbrain DA markers were observed, resulting in a higher total number of DA neurons in vitro and in vivo, whereas the proportion of AHD2-expressing DA neurons was not changed. Our data, using gain-of-function analysis of ES cells, suggest that Pitx3 may be important for specification and/or maintenance of A9-like neuronal properties, while Nurr1 influences overall midbrain DA specification. These findings may be important for modifying ES cells to generate an optimal cell source for transplantation therapy of PD.

Social support and sexually transmitted disease related healthcare utilisation in sexually experienced African-American adolescents

OBJECTIVE

To determine whether adolescents' perceived social support predicts future utilisation of sexually transmitted disease (STD) related health care.

METHODS

A longitudinal study of African-American adolescents ages 12-18 recruited from a random sample of households in the San Francisco Bay area in which baseline data were collected by telephone and follow up data were collected by telephone or in-home audio computer assisted self interview. At baseline, participants were asked about their sexual behaviours, STD history, and social support. At follow up 14-18 months later, participants were asked whether they, while asymptomatic, had sought STD related medical care within the past year.

RESULTS

Asymptomatic sexually experienced adolescents who talked to their closest friend almost every day were more likely to have had STD related health care in the past year (odds ratio (OR) = 1.38; 95% confidence interval (CI) 1.09, 1.76). Closeness to female and male parents/guardians and participation in extracurricular activities were not associated with utilisation of STD related health care within the past year. After controlling for age and sex, sexually experienced adolescents who talked to or saw their closest friend almost every day were more likely to have had STD related health care within the past year (OR = 1.35; 95% CI = 1.08 to 1.70).

CONCLUSIONS

These findings suggest that friends have an impact on the seeking of confidential healthcare services, such as care for STDs.

Postmarketing surveillance of potentially fatal reactions to oncology drugs: potential utility of two signal-detection algorithms

PURPOSE

Several data mining algorithms (DMAs) are being studied in hopes of enhancing screening of large post-marketing safety databases for signals of novel adverse events (AEs). The objective of this study was to apply two DMAs to the United States FDA Adverse Event Reporting System (AERS) database to see whether signals of potentially fatal AEs with cancer drugs might have been identified earlier than with traditional methods.

METHODS

Screening algorithms used for analysis were the multi-item gamma Poisson shrinker (MGPS) and proportional reporting ratios (PRRs). Data mining was performed on data from the FDA AERS database. When a signal was identified, it was compared with that in the year in which the event was added to package insert and/or the year a "case series" was published. A recent publication summarizing the time of dissemination of information on potentially fatal AEs to cancer drugs provided the data set for analysis.

RESULTS

The peer-reviewed published analysis contained 21 drugs and 26 drug-event combinations (DECs) that were considered sufficiently specific for data mining. Twenty-four of the DECs generated a signal of disproportionate reporting with PRRs (6 at 1 year and 16 from 2 years to 18 years prior to either a published "case series" or a package insert change) and 20 with MGPS (3 at 1 year and 11 from 2 years to 16 years prior to either a published "case series" or a package insert change). Two DECs did not signal with either DMA.

CONCLUSION

At least one commonly cited DMA generated a signal of disproportionate reporting for 24 of 26 DECs for selected cancer drugs. For 16 DECs, one could conclude that a signal was generated well in advance (> or =2 years) of standard techniques in use with at least one DMA. DMAs might be useful in supplementing traditional surveillance strategies with oncology drugs and other drugs with similar features. (i.e., drugs that may be approved on an accelerated basis, are known to have serious toxicity, are administered to patients with substantial and complicated comorbid illness, are not available to the general medical community, and may have a high frequency of "off-label" use).