Efficacy, safety and tolerability of rivastigmine capsules in patients with probable vascular dementia: the VantagE study

OBJECTIVE

The aim was to evaluate the efficacy, safety and tolerability of rivastigmine capsules in patients diagnosed with probable vascular dementia (VaD).

METHODS

VantagE (Vascular Dementia trial studying Exelon) was a 24-week, multicentre, double-blind study. VaD patients aged 50-85 years were randomized to rivastigmine capsules (3-12 mg/day) or placebo. Efficacy assessments included global and cognitive performances, activities of daily living and neuropsychiatric symptoms. Adverse events were recorded. Additional exploratory analyses determined whether heterogeneity in pathologies and symptoms extended to differential treatment effects.

TRIAL REGISTRATION

NCT00099216.

RESULTS

710 patients were randomized. Rivastigmine demonstrated superiority over placebo on three measures of cognitive performance (Vascular Dementia Assessment Scale, Alzheimer's Disease Assessment Scale cognitive subscale, Mini-Mental State Examination; all p< or = 0.05, intent-to-treat population [ITT]), but not other outcomes. Predominant adverse events were nausea and vomiting. Exploratory analyses indicated that older patients (> or =75 years old), assumed more likely to also have Alzheimer's disease (AD) pathology, demonstrated significant cognitive responses to rivastigmine and a safety profile similar to that seen in AD patients. Younger patients, assumed less likely to have concomitant AD pathology, showed no efficacy response and were associated with slight elevations of blood pressure, cerebrovascular accidents and mortality. Rivastigmine-placebo differences in patients with, versus those without, medial temporal atrophy (also suggestive of concomitant AD) showed a numerical difference similar to that seen between the older versus younger patients, but did not attain statistical significance.

CONCLUSION

Consistent with trials evaluating other cholinesterase inhibitors, rivastigmine did not provide consistent efficacy in probable VaD. The efficacy apparent on cognitive outcomes was derived from effects in older patients likely to have concomitant Alzheimer pathology. This is supportive of an existing argument that the putative cholinergic deficit in VaD reflects the presence of concomitant Alzheimer pathology.

It takes a village to prevent falls: reconceptualizing fall prevention and management for older adults

Systematic evidence reviews support the efficacy of physical activity programs and multifactorial strategies for fall prevention. However, community settings in which fall prevention programs occur often differ substantially from the research settings in which efficacy was first demonstrated. Because of these differences, alternative approaches are needed to judge the adequacy of fall prevention activities occurring as part of standard medical care or community efforts. This paper uses the World Health Organization Innovative Care for Chronic Conditions (ICCC) framework to rethink how fall prevention programs might be implemented routinely in both medical and community settings. Examples of innovative programs and policies that provide fall prevention strategies consistent with the ICCC framework are highlighted, and evidence where available is provided on the effects of these strategies on processes and outcomes of care. Finally, a "no wrong door" approach to fall prevention and management is proposed, in which older adults who are found to be at risk of falls in either a medical or community setting are linked to a standard fall risk evaluation across three domains (physical activity, medical risks, and home safety).

Composite tissue transplantation: a rapidly advancing field

Composite tissue allotransplantation (CTA) is emerging as a potential treatment for complex tissue defects. It is currently being performed with increasing frequency in the clinic. The feasibility of the procedure has been confirmed through 30 hand transplantation, 3 facial reconstructions, and vascularized knee, esophageal, and tracheal allografts. A major drawback for CTA is the requirement for lifelong immunosuppression. The toxicity of these agents has limited the widespread application of CTA. Methods to reduce or eliminate the requirement for immunosuppression and promote CTA acceptance would represent a significant step forward in the field. Multiple studies suggest that mixed chimerism established by bone marrow transplantation promotes tolerance resulting in allograft acceptance. This overview focuses on the history and the exponentially expanding applications of the new frontier in CTA transplantation: immunology associated with CTA; preclinical animal models of CTA; clinical experience with CTA; and advances in mixed chimerism-induced tolerance in CTA. Additionally, some important hurdles that must be overcome in using bone marrow chimerism to induce tolerance to CTA are also discussed.

Using data on resistance prevalence per sample in the surveillance of antimicrobial resistance

OBJECTIVES

In most existing antimicrobial resistance monitoring programmes, one single bacterial colony from each collected sample is susceptibility tested against a panel of antimicrobials. Detecting the proportion of colonies resistant to different antimicrobials in each sample can provide quantitative data on antimicrobial resistance (resistance prevalence per sample).

METHODS

In this study, a total of 98 faecal samples from slaughter pigs were tested for tetracycline and sulphonamide resistance in Escherichia coli using the single colony method, and these results were compared with the results obtained using the resistance prevalence per sample method.

RESULTS

The results obtained by the resistance prevalence per sample method showed a lower occurrence of resistance. Tetracycline resistance in E. coli was found in 36.7% of the samples using the single colony method, while the mean tetracycline resistance prevalence was 22.5% using the resistance prevalence per sample method. Similarly, sulphonamide resistance was 32.7% using the single colony method and 19.6% when using the resistance prevalence per sample method. Although different estimates were obtained by each method, the correlation test and the regression model demonstrated that there is a significant association between the results obtained using both methods (P value <0.01) for both antimicrobials tested.

CONCLUSIONS

To support risk assessment and analysis of the association between consumption of antimicrobials and occurrence of resistance, there is a need to move towards a more quantitative approach when dealing with antimicrobial resistance in a population, and the resistance prevalence per sample method can provide some of this additional information.

Iris recognition based on key image feature extraction

In iris recognition, feature extraction can be influenced by factors such as illumination and contrast, and thus the features extracted may be unreliable, which can cause a high rate of false results in iris pattern recognition. In order to obtain stable features, an algorithm was proposed in this paper to extract key features of a pattern from multiple images. The proposed algorithm built an iris feature template by extracting key features and performed iris identity enrolment. Simulation results showed that the selected key features have high recognition accuracy on the CASIA Iris Set, where both contrast and illumination variance exist.

Field studies on the environmental factors in controlling microcystin production in the subtropical shallow lakes of the Yangtze River

Microcystin (MC) problem made more and more care about in China, intercellular MC (Int-MC) and cellular MC (Cel-MC) were important contents to reflect the producing-MC ability by cyanobacteria and by lakes. To study the correlations between Int-MC, Cel-MC concentration and biological and environmental factors, eight cyanobacterial blooming lakes were studied in the middle and lower reaches of the Yangtze River. Microcystin-RR (MC-RR) and Microcystin-LR (MC-LR) were the primary toxin variants in our data. From the linear correlations between MC and environmental factors, cellular-YR had significant correlation with most of chemical factors except total nitrogen (TN) and the ratio of total nitrogen and total phosphorus (TN/TP), most intracellular MC analogues had significant correlations with total dissolved nitrogen (TDN), ammonium (NH (4) (+) ), nitrite (NO (2) (-) ), TP, total dissolved phosphorus (TDP), Microcystis. From the canonal correspondence analysis, Int-MC concentrations were closely related with the chemical and biological factors, such as TP, total organic carbon (TOC), chlorophyll a (Chl a), Microcystis biomass, et al. While Cel-MC contents, especially Cel-RR and Cel-LR, were closely related with light environmental in the lakes such as water depth and transparence.

Dynamic overload control for distributed call processors using the neural network method

Overload control of call processors in telecom networks is used to protect the network of call processing computers from excessive load during traffic peaks, and involves techniques of predictive control with limited local information. Here we propose a neural-network algorithm, in which a group of neural controllers are trained using examples generated by a globally optimal control method. Simulations show that the neural controllers have better performance than local control algorithms in both the throughput and the response to traffic upsurges. Compared with the centralized control algorithm, the neural control significantly decreases the computational time for making decisions and can be implemented in real time.

Admixture and population stratification in African Caribbean populations

Throughout biomedical research, there is growing interest in the use of ancestry informative markers (AIMs) to deconstruct racial categories into useful variables. Studies on recently admixed populations have shown significant population substructure due to differences in individual ancestry; however, few studies have examined Caribbean populations. Here we used a panel of 28 AIMs to examine the genetic ancestry of 298 individuals of African descent from the Caribbean islands of Jamaica, St. Thomas and Barbados. Differences in global admixture were observed, with Barbados having the highest level of West African ancestry (89.6%+/- 2.0) and the lowest levels of European (10.2%+/- 2.2) and Native American ancestry (0.2%+/- 2.0), while Jamaica possessed the highest levels of European (12.4%+/- 3.5) and Native American ancestry (3.2%+/- 3.1). St. Thomas, USVI had ancestry levels quite similar to African Americans in continental U.S. (86.8%+/- 2.2 West African, 10.6%+/- 2.3 European, and 2.6%+/- 2.1 Native American). Significant substructure was observed in the islands of Jamaica and St. Thomas but not Barbados (K=1), indicating that differences in population substructure exist across these three Caribbean islands. These differences likely stem from diverse colonial and historical experiences, and subsequent evolutionary processes. Most importantly, these differences may have significant ramifications for case-control studies of complex disease in Caribbean populations.

Testosterone protects rat hearts against ischaemic insults by enhancing the effects of alpha(1)-adrenoceptor stimulation

BACKGROUND AND PURPOSE

Testosterone alleviates symptoms in patients with ischaemic heart disease. Androgen receptors are present in the heart, and testosterone upregulates gene expression of cardiac beta(1)-adrenoceptors. We hypothesize that testosterone may confer cardioprotection by interacting with adrenoceptors.

EXPERIMENTAL APPROACH

In isolated perfused hearts and ventricular myocytes from orchidectomized rats without or with testosterone (200 microg/100 g) replacement, we first determined the effect of ischaemia/reperfusion in the presence of noradrenaline (10(-7) M). Then we determined the contribution of interactions between testosterone and alpha(1)- or beta(1)-adrenoceptors in cardiac injury/protection (infarct size, release of lactate dehydrogenase, viability of myocytes, recovery of contractile function and incidence of arrhythmias) upon ischaemia/reperfusion by pharmacological manipulation using selective adrenoceptor agonists (alpha(1)-adrenoceptor agonist: phenylephrine 10(-6) M; non-selective beta-adrenoceptor agonist: isoprenaline 10(-7) M) and antagonists (alpha(1): prazosin or benoxathian 10(-6) M; beta(1): CGP 20712A 5 x 10(-7) M). We also determined the expression of alpha(1) and beta(1)-adrenoceptor in the hearts from rats with and without testosterone.

KEY RESULTS

Testosterone reduced injury induced by ischaemia/reperfusion and noradrenaline. This was achieved by enhancing the beneficial effect of alpha(1)-adrenoceptor stimulation, which was greater than the deleterious effect of beta(1)-adrenoceptor stimulation (also enhanced by testosterone). The effects of testosterone were abolished or attenuated by blockade of androgen receptors. Testosterone also enhanced the expression of alpha(1A) and beta(1)-adrenoceptor.

CONCLUSIONS AND IMPLICATIONS

Testosterone conferred cardioprotection by upregulating the cardiac alpha(1)-adrenoceptor and enhancing the effects of stimulation of this adrenoceptor. The effect of testosterone was at least partly mediated by androgen receptors.

The immunosuppressive and protective ability of glucose-regulated protein 78 for improvement of alloimmunity in beta cell transplantation

An insulinoma cell line, NIT-1, transfected with glucose-regulated protein 78 (GRP78) was established, namely NIT-GRP78, and used to study the immunosuppressive and protective ability of GRP78. In extended cytotoxic T lymphocyte (CTL) killing assay, NIT-1-primed lymphocytes were more cytotoxic in killing beta cells than NIT-GRP78-primed lymphocytes. Severe necrosis was observed only when the NIT-1-primed lymphocytes were cultured with NIT-1 beta cells, but not with NIT-GRP78 cells. In addition, an increase of interleukin (IL)-4 secretion from beta cell-primed splenocytes when GRP78 presence was observed in cytokine enzyme-linked immunosorbent assay (ELISA). Diabetic mice reached normoglycaemia promptly and gained weight after transplantation of either NIT-1 or NIT-GRP78 cells. However, the recipient mice transplanted with NIT-GRP78 cells lived much longer than those recipients transplanted with NIT-1 cells, which was due apparently to prolonged insulin production by the transplanted NIT-GRP78 cells. In fact, we observed a significant increase of insulin concentration after glucose stimulation of diabetic mice received NIT-GRP78 cells at day 7 post-transplantation. From the results we propose that GRP78 could have a dual function in both protecting NIT-1 cells from CTL-mediated lysis and stimulating a population of T helper 2 cells to down-regulate the immune response to the transplanted beta cells.