Developing tomorrow's antipsychotics: the need for a more personalised approach

There has been little pharmacological advance in the treatment of schizophrenia since the introduction of chlorpromazine in the 1950s. This may be set to change as recent advances in molecular biology offer the prospect of a better understanding of the pathophysiology of the disorder and allow investigation of the complex interplay of genetic and environmental risk factors. In this review I discuss future approaches to antipsychotic drug development, highlighting the need to better define symptom areas and develop drugs based on an understanding of neurobiological mechanisms. The development of biomarkers has the potential in future to improve differential diagnosis and help predict response to treatment. These developments herald the possibility of a more integrated drug discovery approach and the subsequent provision of more stratified healthcare, and hopefully significant improvements in patient care and improved long-term outcomes.

Randomised feasibility study of physiotherapy for patients with functional motor symptoms

OBJECTIVE

To determine the feasibility of conducting a randomised controlled trial of a specialist physiotherapy intervention for functional motor symptoms (FMS).

METHODS

A randomised feasibility study was conducted recruiting patients with a clinically established diagnosis of FMS from a tertiary neurology clinic in London, UK. Participants were randomised to the intervention or a treatment as usual control. Measures of feasibility and clinical outcome were collected and assessed at 6 months.

RESULTS

60 individuals were recruited over a 9-month period. Three withdrew, leaving 29 intervention and 28 controls participants in the final analysis. 32% of patients with FMS met the inclusion criteria, of which 90% enrolled. Acceptability of the intervention was high and there were no adverse events. At 6 months, 72% of the intervention group rated their symptoms as improved, compared to 18% in the control group. There was a moderate to large treatment effect across a range of outcomes, including three of eight Short Form 36 (SF36) domains (d=0.46-0.79). The SF36 Physical function was found to be a suitable primary outcome measure for a future trial; adjusted mean difference 19.8 (95% CI 10.2 to 29.5). The additional quality adjusted life years (QALY) with intervention was 0.08 (95% CI 0.03 to 0.13), the mean incremental cost per QALY gained was £12 087.

CONCLUSIONS

This feasibility study demonstrated high rates of recruitment, retention and acceptability. Clinical effect size was moderate to large with high probability of being cost-effective. A randomised controlled trial is needed.

TRIAL REGISTRATION NUMBER

NCT02275000; Results.

The analysis of a Puerto Rican cohort of Essential Thrombocytemia patients

Essential Thrombocytemia (ET) disorder, part of the group of myeloproliferative disorders, has been related to acquired mutations that constitutively activate the JAK2 pathway, accordingly JAK2V617F is present in the 56% of ET patients. ET decreases life expectancy and its effects are detrimental on the mid-fifties population, therefore, it is important to understand and devise methods to improve its treatment. For this reason, we completed a comparative analysis of 37 different cytokines in a cohort of 23 Puerto Rican ET patients and 11 controls. Using Mann Whitney comparative analysis between the status of the JAK2V617F mutation and cytokine profiles have revealed that JAK2V617F positive patients have a significantly higher median values of IL-19 (ET: 6.48 pg/ml; control: 5.13 pg/ml, p-value: 0.0076), Il-28/IFNλ2 (ET: 3.76 pg/ml; control: 2.79 pg/ml, p-value: 0.0422) and IL-29/IFNλ1 (ET: 14.47 pg/ml; control: 10.3 pg/ml, p-value: 0.0332) when compared with healthy controls. TWEAK TNFSF12 (ET: 40.05 pg/ml; control: 47.77 pg/ml, p-value: 0.0437), however was significantly lower in this population. Also, we have found that JAK2V617F negative patients have significantly higher levels of IFN-α2 (ET: 14.82 pg/ml; control: 12.53 pg/ml p-value: 0.0096), IL-8 (ET: 6.93 pg/ml; control: 6.33 pg/ml, p-value: 0.0316), and IL-22 (ET: 7.865 pg/ml; control: 6.23 pg/ml, p-value: 0.0087) than control patients. Moreover, we have found that ET CALR mutants have significantly lower median levels of MPP-3 and that ET patients have higher TLT-1 levels than control patients. Together these findings could be used to enhance the characterization and improve prognosis and treatment of ET patients.

Effect of Histophilus somni on Heart and Brain Microvascular Endothelial Cells

Histophilus somni is a pathogenic gram-negative bacterium responsible for pneumonia and septicemia in cattle. Sequelae include infectious thrombotic meningoencephalitis (ITME), myocarditis, arthritis, and abortion. These syndromes are associated with widespread vasculitis and thrombosis, implicating a role for endothelium in pathogenesis. Histopathologic and immunohistochemical investigation of 10 natural cases of bovine H. somni myocarditis and 1 case of ITME revealed intravascular H. somni in large biofilm-like aggregates adherent to the luminal surface of microvascular endothelium. Ultrastructurally, bacterial communities were extracellular and closely associated with degenerating or contracted endothelial cells. Histophilus somni was identified by bacterial culture and/or immunohistochemistry. Western blots of the bacterial isolates revealed that they expressed the immunodominant protective 40 kDa OMP and immunoglobulin-binding protein A (IbpA) antigens. The latter is a large surface antigen and shed fibrillar antigen with multiple domains. The cytotoxic DR2Fic domain of IbpA was conserved as demonstrated by polymerase chain reaction. Treatment of endothelial cells in vitro with IbpA in crude culture supernatants or purified recombinant GST-IbpA DR2Fic (rDR2) cytotoxin induced retraction of cultured bovine brain microvascular endothelial cells. By contrast, no retraction of bovine endothelium was induced by mutant rDR2H/A with an inactive Fic motif or by a GST control, indicating that the cytotoxic DR2Fic motif plays an important role in endothelial cell retraction in vasculitis. The formation of biofilm-like aggregates by H. somni on bovine microvascular endothelium may be fundamental to its pathogenesis in heart and brain.