Effects of chronic doxepin and amitriptyline administration in naïve mice and in neuropathic pain mice model

Neuropathic pain is a severe clinical problem, often appearing as a co-symptom of many diseases or manifesting as a result of damage to the nervous system. Many drugs and agents are currently used for the treatment of neuropathic pain, such as tricyclic antidepressants (TCAs). The aims of this paper were to test the effects of two classic TCAs, doxepin and amitriptyline, in naïve animals and in a model of neuropathic pain and to determine the role of cytokine activation in the effects of these drugs. All experiments were carried out with Albino-Swiss mice using behavioral tests (von Frey test and the cold plate test) and biochemical analyses (qRT-PCR and Western blot). In the mice subjected to chronic constriction injury (CCI), doxepin and amitriptyline attenuated the symptoms of neuropathic pain and diminished the CCI-induced increase in the levels of spinal interleukin (IL)-6 and -1β mRNA, but not the protein levels of these cytokines, measured on day 12. Unexpectedly, chronic administration of doxepin or amitriptyline for 12 days produced allodynia and hyperalgesia in naïve mice. The treatment with these drugs did not influence the spinal levels of IL-1β and IL-6 mRNA, however, the protein levels of these pronociceptive factors were increased. The administration of ondansetron (5-HT3 receptor antagonist) significantly weakened the allodynia and hyperalgesia induced by both antidepressants in naïve mice; in contrast, yohimbine (α2-adrenergic receptors antagonist) did not influence these effects. Allodynia and hyperalgesia induced in naïve animals by amitriptyline and doxepin may be associated with an increase in the levels of pronociceptive cytokines resulting from 5-HT3-induced hypersensitivity. Our results provide new and important information about the possible side effects of antidepressants. Further investigation of these mechanisms may help to guide decisions about the use of classic TCAs for therapy.

The progressive myoclonic epilepsies

Progressive myoclonic epilepsies are a group of disorders characterised by a relentlessly progressive disease course until death; treatment-resistant epilepsy is just a part of the phenotype. This umbrella term encompasses many diverse conditions, ranging from Lafora body disease to Gaucher's disease. These diseases as a group are important because of a generally poor response to antiepileptic medication, an overall poor prognosis and inheritance risks to siblings or offspring (where there is a proven genetic cause). A correct diagnosis also helps patients and their families to accept and understand the nature of their disease, even if incurable. Here, we discuss the phenotypes of these disorders and summarise the relevant specific investigations to identify the underlying cause.

Cognition enhancers for the treatment of dementia

Dementia is a broad term used to describe several chronic progressive neurological disorders that adversely affect higher mental functions including memory, language, behaviour, abstract thinking, comprehension, calculation, learning capacity and judgement. Alzheimer's disease is the most common form of dementia but other neurological conditions such as Parkinson's disease, cerebrovascular disease and chronic infections such as syphilis can also lead to the clinical syndrome of dementia. Initial investigations should always focus on finding any treatable cause for dementia such as HIV, structural lesions such as subdural haematomas or specific nutritional deficiency states such as that due to vitamin B12 and treated appropriately. Where no treatable or reversible aetiology is found, a referral to a specialist should be considered who may initiate further investigations including magnetic resonance imaging or perfusion single-photon emission computerised tomography scans of the brain, and sometimes cerebrospinal fluid examination or an electroencephalogram.

Alpha-synuclein in peripheral tissues and body fluids as a biomarker for Parkinson's disease - a systematic review

Parkinson's disease (PD) is neuropathologically characterized as an alpha-synucleinopathy. Alpha-synuclein-containing inclusions are stained as Lewy bodies and Lewy neurites in the brain, which are the pathological hallmark of PD. However, alpha-synuclein-containing inclusions in PD are not restricted to the central nervous system, but are also found in peripheral tissues. Alpha-synuclein levels can also be measured in body fluids. The aim of this study was to conduct a systematic review of available evidence to determine the utility of alpha-synuclein as a peripheral biomarker of PD. We searched PubMed (1948 to 26 May 2013), Embase (1974 to 26 May 2013), the Cochrane Library (up to 26 May 2013), LILACS (up to 26 May 2013) and CINAHL (up to 26 May 2013) for the studies of alpha-synuclein in peripheral tissues or body fluids in PD. A total of 49 studies fulfilled the search criteria. Peripheral tissues such as colonic mucosa showed a sensitivity of 42-90% and a specificity of 100%; submandibular salivary glands showed sensitivity and specificity of 100%; skin biopsy showed 19% sensitivity and 80% specificity in detecting alpha-synuclein pathology. CSF alpha-synuclein had 71-94% sensitivity and 25-53% specificity for distinguishing PD from controls. Plasma alpha-synuclein had 48-53% sensitivity and 69-85% specificity. Neither plasma nor CSF alpha-synuclein is presently a reliable marker of PD. This differs from alpha-synuclein in solid tissue samples of the enteric and autonomic nervous system, which offer some potential as a surrogate marker of brain synucleinopathy.

Inhaled apomorphine in patients with 'on-off' fluctuations: a randomized, double-blind, placebo-controlled, clinic and home based, parallel-group study

BACKGROUND

In later stages of Parkinson's disease, treatment of 'off' periods with subcutaneous apomorphine is helpful but requires injection; inhaled apomorphine would be potentially more convenient.

OBJECTIVES

To identify optimal efficacy, safety and tolerability for inhaled apomorphine in reversing Parkinson's disease 'off' periods.

METHODS

A randomized, double-blind, 2:1 active:placebo, parallel-group, ascending dose titration study was conducted at 16 centres in 3 countries. Inhaled apomorphine was administered under observation, at escalating fine particle doses of 1.5, 2.5, 3.5 and 4.5 mg. This was followed by at-home patient self-treatment for 2 to 4 weeks, assessed from 'on-off' diaries.

RESULTS

In 55 patients, mean age 65.6 years (range 47-79), mean disease duration 12 years (range 5-22), the mean improvement in the unified PD rating scale part 3 (UPDRS 3) was significantly greater for apomorphine (mean dose 2.3 mg) at 19.5 (standard deviation 13.6) than for placebo at 9.9 (9.6), least squares mean difference 8.4 (95% confidence interval 1.2 to 15.5, p = 0.023). During at-home testing, mean 'off' time per day was reduced by 139.8 minutes (standard deviation 149.6) for apomorphine versus 68.0 (108.6) minutes for placebo, least squares mean difference not significant at 100.5 minutes (95% confidence interval -12.0 to 212.9, p = 0.078). The onset of action was faster for apomorphine (mean 8.1 SD 6.2 minutes) than placebo (mean 13.1 SD 6.6 minutes) (p < 0.0001). Reversal of 'off' episodes was significantly more likely for episodes treated with apomorphine than those treated with placebo: apomorphine 64.6% SD 32.3 of episodes versus placebo 11.1% SD 15.3 (p < 0.0001). During at-home treatment, 36% of apomorphine and 20% of placebo patients experienced adverse events.

CONCLUSIONS

Inhaled apomorphine in the dose range 1.5 to 4.5 mg, significantly improved UPDRS 3 scores in the clinic, and aborted a greater proportion of 'off' periods at-home, compared to placebo. However, daily 'off' time was not significantly reduced by the use of inhaled apomorphine.

Transpapillary retrieval of a proximally migrated stent using a three-prong polyp retrieval device in a 2-years-old girl

Endoscopic retrieval of proximally migrated biliary stents is sometimes challenging. We report on the successful use of a three-prong colon polyp retrieval device in a two year old child.

Baseline [(123) I]FP-CIT SPECT (DaTSCAN) severity correlates with medication use at 3 years in Parkinson's disease

BACKGROUND

Presynaptic dopaminergic deficiency on dopamine transporter imaging supports a clinical diagnosis of Parkinson's disease and correlates with the severity of rigidity and bradykinesia. Baseline dopaminergic deficiency predicts clinical severity, but the relationship with subsequent medication use has not been reported.

METHODS

A randomly selected cross section of 83 Parkinson's disease (PD) patients who had [(123) I] FP-CIT SPECT at the time of clinical diagnosis was identified. Dopaminergic deficiency was graded 1, 2 or 3 with increasing severity using visual assessment and by semiquantitative analysis of putamen and caudate uptake. Antiparkinson medication usage and clinical severity by Hoehn and Yahr were noted annually to 3 years.

RESULTS

In 83 patients (66% male, median age 65.0 years, IQ 55.4-71.8), [(123) I]FP-CIT SPECT was grade 1 in 20 (24%), grade 2 in 53 (64%) and grade 3 in 10 patients (12%). Dopamine transporter uptake ratios were inversely associated with antiparkinson medication usage (r = -0.26, P = 0.0201) and Hoehn Yahr stage (r = -0.32, P = 0.0029) at 3 years from baseline, but there was considerable variation in drug usage in individual patients. At 3 years, patients with grade 1 scans at baseline received a median dose of 325 levodopa equivalent units (LEU) (interquartile range 175-433); grade 2 scan patients 400 LEU (interquartile range 300-635); and grade 3 scan patients 460 LEU (interquartile range 252-658).

CONCLUSION

The degree of reduction in presynaptic dopaminergic uptake at baseline is associated with higher antiparkinson drug dosage at follow-up, but the wide variation means that the baseline FP-CIT SPECT does not reliably predict drug use in individual cases.

Inhaled dry powder apomorphine (VR040) for 'off ' periods in Parkinson's disease: an in-clinic double-blind dose ranging study

BACKGROUND

'Off' periods increase as Parkinson's disease (PD) progresses and the benefits of standard therapy wane. Subcutaneous apomorphine rescues 'off' periods, but patient self-injection and adverse cutaneous effects are sometimes problematic.

METHODS

We assessed safety, tolerability and efficacy of inhaled dry powder apomorphine (VR040) in a double-blind clinic-based Phase II study. Of 48 patients recruited at nine sites, 47 were randomized 2:1 inhaled apomorphine/placebo. Respirable doses (drug predicted to reach the lung), ascending through 1.5, 2.3, 3.0 and 4.0 mg until efficacy was achieved, were administered to patients in a practically defined 'off' state. The primary endpoint was the response in unified PD rating scale Part 3 (UPDRS 3), at the highest dose received by the patient. Secondary endpoints included time to 'on', the proportion of patients converting from 'off' to 'on', and duration of 'on'.

RESULTS

In the 47 intent-to-treat patients with PD, mean age 60.6 years, the mean UPDRS 3 improvement was significantly greater for VR040 at 26.8 points (standard deviation 12.0), vs 14.9 (16.3) for placebo (treatment difference 11.6, 95% confidence interval 2.3-20.9, P = 0.016). Rapid apomorphine absorption (2-7 min) translated to rapid (mean 10 min) reversal from the 'off' state. Adverse effects did not differ between VR040 and placebo; no patient discontinued due to an adverse event; one serious adverse event (constipation) in the VR040 group was considered unrelated to trial medication.

CONCLUSIONS

Inhaled apomorphine shows significant promise as a replacement for intermittent subcutaneous injections; further studies are appropriate to optimize efficacy and tolerability.

Phase IIa randomized double-blind, placebo-controlled study of inhaled apomorphine as acute challenge for rescuing 'off' periods in patients with established Parkinson's disease

BACKGROUND AND PURPOSE

In this first study of inhaled apomorphine (VR040) in patients with Parkinson's disease, the primary objective was to find the minimum efficacious dose of apomorphine that was useful in rescuing patients during 'off' periods. Safety, tolerability and pharmacokinetics of inhaled apomorphine were assessed during the study.

METHODS

A double-blind, placebo-controlled, randomized trial of three escalating single doses of inhaled apomorphine (0.2, 0.5 and 0.8 mg fine particle dose) versus placebo (3 : 1 active:placebo) was performed. Parkinson's motor severity assessments by a clinician, and disease state assessment by the patient, were performed at baseline during an 'off' state, and at specified times after test drug administration. Safety assessments (including vital signs, electrocardiogram and forced expiratory volume) were performed, and plasma apomorphine levels measured.

RESULTS

All 24 patients completed the study, and considering the three dose levels together, inhaled apomorphine did not significantly increase the proportion of patients switching from 'off' to 'on' (0/6 at 0.2 mg, 3/6 at 0.5 mg and 2/6 at 0.8 mg vs. 1/6 for placebo), or decrease the time from 'off' to 'on' post-treatment (10 min for 0.5 mg, 40 min for 0.8 mg, vs. 20 min for placebo). However, there was a suggestion of benefit at the higher doses (5/12 switched 'on' at the 0.5 or 0.8 mg doses, vs. 1/6 for placebo). There were no serious adverse events and treatment was well tolerated. Peak plasma concentration was 1-3 min post-dose, and plasma level dose proportionality was observed.

CONCLUSIONS

Inhaled apomorphine was safe and well tolerated at the doses tested for an acute challenge to rescue 'off' periods, but efficacy at these doses was limited. A follow-up study at higher doses is appropriate given these initial findings.

VSV virotherapy improves chemotherapy by triggering apoptosis due to proteasomal degradation of Mcl-1

Overexpression of myeloid cell leukemia 1 protein (Mcl-1), an anti-apoptotic B-cell lymphoma 2 (Bcl-2) family member, contributes to chemotherapy resistance of tumors. The short half-life of Mcl-1 makes it an interesting target for therapeutic agents that negatively interfere with cellular protein biosynthesis, such as oncolytic viruses. Vesicular Stomatitis Virus (VSV) has been established as the oncolytic virus that efficiently disrupts de novo protein biosynthesis of infected cells. Here, we show that after VSV infection, Mcl-1 protein levels rapidly declined, whereas the expression of other members of the Bcl-2 family remained unchanged. Mcl-1 elimination was a consequence of proteasomal degradation, as overexpression of a degradation-resistant Mcl-1 mutant restored Mcl-1 levels. Mcl-1 rescue inhibited apoptosis and thereby confirmed that Mcl-1 downregulation contributes to VSV-induced apoptosis. In vitro, VSV virotherapy in combination with chemotherapy revealed an enhanced therapeutic effect compared with the single treatments, which could be reverted by Mcl-1 rescue or RNA interference (RNAi)-mediated knockdown of pro-apoptotic Bax and Bak proteins. Finally, in a tumor mouse model, combinations of doxorubicin and VSV showed a superior therapeutic efficacy compared with VSV or doxorubicin alone. In summary, our data indicate that VSV virotherapy is an attractive strategy to overcome tumor resistance against conventional chemotherapy by elimination of Mcl-1.

[Sorafenib for the treatment of HCC--the beginning of a new era in the treatment of HCC]

Sorafenib increases overall survival in patients with advanced HCC by almost three months. However, despite these advances in the treatment of patients with HCC, average overall survival remains below one year. Based on our understanding of hepatocarcinogenesis, the development of new molecular targeting agents and results from biomarker studies in HCC, new therapeutic treatment options are currently being investigated. We summarize recent results on the molecular therapy for HCC and discuss how these can be efficiently tested in patients with HCC.

Three-dimensional sonographic assessment of fetal urine production before and after laser surgery in twin-to-twin transfusion syndrome

OBJECTIVE

Fetal urine production in twin-to-twin transfusion syndrome (TTTS) reflects the hemodynamic imbalance between the donor and recipient twins but it has not been measured in this particular condition. The aim of this study was to measure fetal urine production using three-dimensional (3D) ultrasound in donor and recipient twins before and after laser treatment for TTTS and to correlate this with umbilical venous volume flow (UVVF).

METHODS

Urine production rate (UPR) was measured using 3D ultrasound with Virtual Organ Computer-aided AnaLysis (VOCAL) in 106 cases of severe TTTS. The rotation angle was set at 30 degrees . The bladder volume was measured twice in each fetus (V(1) and V(2)), with an interval of 5-30 min between measurements, in order to calculate the UPR. When V(2) > V(1), UPR was calculated using the formula: V(2) - V(1) /time interval. Together with UPR, UVVF was measured before and after treatment. Both parameters were corrected for fetal weight. Inter- and intraobserver variability were calculated in 16 cases using the intraclass correlation coefficient.

RESULTS

Before laser treatment, UPR was significantly higher in recipients compared with donors (median, 14.8 and 0 mL/h/kg, mean 23.8 and 2.3 mL/h/kg, respectively, P < 0.001), and UPR was positively correlated with UVVF in both twins. Following laser treatment (48 h later), UPR decreased to 9 mL/h/kg (P < 0.001) in recipients, while there was no change in donors. UVVF increased significantly from a median value of 92 to 132 mL/min/kg (P < 0.01) in donors and decreased significantly from 150 to 99 mL/min/kg (P < 0.001) in recipients.

CONCLUSIONS

In TTTS UPR is correlated to UVVF and reflects the hemodynamic imbalance between donor and recipient twins. Following laser treatment, UPR decreases in recipients but is unaffected in donors. However, changes in UVVF occur in both twins. This suggests that although fetal renal function is driven by fetal hemodynamics, there may be a lag in the recovery of renal function in the donor twin.

Maternal and fetal alphafetoprotein (AFP) levels at term. Relation to sex, weight and gestation of the infant

Serum alpha-fetoprotein (AFP) was measured in maternal, cord arterial and venous blood. Samples were collected at the time of vaginal delivery from 105 women at 36-42 weeks' gestation. There was a significant correlation between maternal, cord arterial and venous AFP. Umbilical cord arterial and venous AFP levels were considerably higher in male infants than in females. Umbilical AFP levels declined with lengthening gestation and increasing birthweight for both male and female infants and a similar pattern was seen in the mother. Fetal AFP levels were significantly higher in subjects giving birth at 40 weeks whose infants had a birthweight below the population mean vis-à-vis those above the mean. It is concluded that the absolute size of the fetus as well as gestational age may play a significant role in determining maternal and fetal AFP concentration.

Functional evaluation of tendon interposition arthroplasty of the trapeziometacarpal joint

The carpometacarpal joint of the thumb is a frequent site of pain and disability secondary to arthritis. Surgical treatment for this disease has included arthrodesis, excision, total joint replacement, ligament reconstruction, and tendon or synthetic interposition arthroplasty. The aim of treatment is a functional, pain-free thumb. This study includes 11 patients operated upon utilizing tendon interposition arthroplasty; three patients had bilateral surgery. The primary disease was osteoarthritis in nine patients and rheumatoid arthritis in two. Average followup length postoperatively was 53 months. All patients experienced increased function and alleviation of pain after surgery. Average key pinch measured 8.4 pounds in the osteoarthritic female group. Palmar and radial abduction as well as opposition were full postoperatively. This study shows that tendon arthroplasty provides a painless, well-functioning thumb. Its main advantages over other procedures are the acceptable range of motion obtained, a short postoperative immobilization period, and the ease of its surgical technique. Indexing terms: tendon arthroplasty; osteoarthritis; rheumatoid arthritis; trapeziometacarpal joint.