Molecularly targeted therapies for malignant gliomas: advances and challenges

The identification of molecular markers associated with tumor but not with normal tissue has allowed the development of highly specific, targeted therapies for the treatment of cancer. Over the last several years, tremendous advances in our understanding of the genetic and molecular changes involved in the progression of malignant gliomas have triggered a large effort in the development of targeted therapies to treat these tumors. However, to date only a modest clinical benefit, limited to subsets of patients, has been demonstrated. Furthermore, despite a high degree of target selectivity, the use of targeted therapies often has systemic toxicity. The reasons behind this limited clinical success are complex and include the intricacy of the signaling pathways in gliomas and the heterogeneity of the disease process, compounded by existing limitations in assessing the efficacy of these novel agents when conventional end points and clinical trial designs are utilized. However, despite these difficulties targeted therapies remain a very attractive avenue of treatment for malignant gliomas. Three basic approaches are needed to overcome the hurdles associated with targeted therapies: first, further development of genetic profiling techniques will help to better determine the genetic changes and molecular pathways involved in gliomas and will potentially allow the design of individualized therapies based on the genetic and molecular signature of each tumor. Second, there is a need for the development of better combination strategies (complementary targeted agents or targeted agents with chemotherapy drugs) directed towards disease heterogeneity. Third, we need to optimize the design of preclinical and clinical trials to obtain the maximum amount of information in the shortest period of time.

Beyond symptomatic therapy: a re-examination of acetylcholinesterase inhibitors in Alzheimer’s disease

Acetylcholinesterase inhibitors (AChEIs) are generally regarded as palliative treatments for Alzheimer's disease that slow the progression of dementia symptoms without altering Alzheimer's disease's underlying pathogenic mechanisms. This concept is based on inference rather than evidence, and has limited the scope and persistence of AChEI use in clinical practice. Recent preclinical studies demonstrate that AChEIs exhibit a number of biological effects in addition to cholinesterase inhibition. A broader understanding of the possible mechanisms of action of AChEIs in Alzheimer's disease could result in more effective use and assist in the development of new and improved therapies. The available evidence brings into question the prevailing view that AChEIs are exclusively symptomatic treatments and supports the use of these agents persistently throughout the course of Alzheimer's disease.

IASP global year against pain in older persons: highlighting the current status and future perspectives in geriatric pain

This year represents the international year against pain in older persons and it is opportune, therefore, to reflect upon the current status and possible future directions in pain-management practice for this large and growing segment of the population. Epidemiologic studies show a very high prevalence of persistent pain, often exceeding 50% of community-dwelling older persons and up to 80% of nursing home residents. Recently, there has been a major push to develop age-appropriate pain assessment tools, including several observer-rated scales of behavioral pain indicators for use in those with dementia. There has also been the release of several comprehensive guidelines for the assessment and management of pain in older persons, although the current evidence-base used to guide clinical practice is extremely limited. Unfortunately, despite these advances, pain remains grossly under treated in older persons, regardless of the healthcare setting. With the demographic imperative of a rapidly aging society, much greater attention is now being devoted to the problem of geriatric pain, with new initiatives in healthcare planning, calls for better professional education in geriatrics and pain management as well as new directions and funding resources for research into this important problem. Of course, this increased awareness must still be translated into action, not just because better pain relief for older adults is an ethically desirable outcome, but out of the sheer necessity of dealing with the millions of older persons who will suffer from persistent and bothersome pain in the years to come.

Spectrum of effectiveness of valproate in neuropsychiatry

Valproate is principally effective in manic aspects of bipolar disorder. Tolerability has been somewhat more favorable for valproate than comparators, with the frequent adverse effects being gastrointestinal disturbances and weight gain. Total cholesterol and low-density lipoproteins are reduced by valproate. Valproate is effective and well tolerated when combined with lithium or antipsychotic drugs. Valproate is efficacious in mixed and euphoric mania. In studies of maintenance versus placebo and active comparators, patients initially treated with divalproex for mania had more robust long-term benefits than in the full sample analyses. In maintenance treatment, patients whose valproate serum levels were between 75 and 99 microg/ml had longer time to discontinuation for any reason or a new mood episode than did patients receiving placebo. The profile of utility in bipolar disorders is principally for core features of manic symptomatology (e.g., impulsivity, hyperactivity and irritability), with little evidence of benefit for anxiety or psychosis. Valproate appears useful in other disorders that have behavioral dimensions inclusive of the domains that valproate benefits in bipolar disorders, such as schizophrenia.

Innovations and recent trends in the treatment of ADHD

Initiatives to develop better-tolerated, more efficacious pharmacological agents with improved drug delivery systems have driven recent research in attention-deficit hyperactivity disorder (ADHD). While stimulants are the primary pharmacotherapy for ADHD, these drugs have a limited duration of action and a subset of patients will either fail to respond to these medications or have side effects that preclude their use. The development of atomoxetine, the first nonstimulant approved for ADHD, has been followed by additional innovative research, such as the methylphenidate transdermal system, modafinil, NRP-104 and cholinergic agents. This review highlights some of the recent trends in ADHD treatment and the current status of promising treatment options that may help to shape the future of ADHD treatment.

Role of aripiprazole in treating mood disorders

Atypical antipsychotics have been used to treat patients with schizophrenia for many years, but now there is increasing evidence of their utility in the treatment of mood disorders. In the past few years, several atypical agents have received regulatory approval for use in mania. The evidence shows that atypical antipsychotics are effective in the treatment of manic symptoms, either alone or in combination with traditional mood stabilizers, such as lithium and divalproex. Although emerging data indicate that atypical antipsychotics will be a promising addition to those therapies that are currently available for managing patients during the maintenance phase of bipolar illness, their potential in the long-term management of bipolar disorder remains to be fully explored. Aripiprazole is a recently released antipsychotic medication that differs from other atypical antipsychotic agents by its mode of action as a dopamine D2 partial agonist. It is administered orally and has a long half-life. Randomized studies have demonstrated the efficacy of aripiprazole compared with placebo in the treatment of acute relapse of schizophrenia and schizoaffective disorder, maintenance treatment of schizophrenia, treatment of acute mania, and prevention of manic relapse in patients who responded to the drug during a manic episode. Further studies are ongoing in bipolar and unipolar depression. Aripiprazole is generally well tolerated compared with other antipsychotic medications, although commonly reported side effects include extrapyramidal symptoms and motoric activation similar to akathisia. Further studies and postmarketing data will be helpful in providing additional information regarding the comparative safety, efficacy and tolerability of aripiprazole in the treatment of affective disorders.

Developments towards an artificial kidney

This article reviews the present state of renal failure and its treatment in the industrialized world. Novel and experimental therapies for the treatment of renal failure are covered, with special emphasis on a hybrid bioartificial kidney currently undergoing clinical trials in the USA. Preclinical data, results from human trials and work on miniaturization of the bioartificial kidney for implantation are presented. Research on microfluidics and nanotechnology applied to dialysis is ongoing in many academic centers, and several promising approaches are discussed. After 10 years of incremental improvements in end-stage renal disease care, several revolutionary technologies are on the horizon and approaching the marketplace.

Could agomelatine be the ideal antidepressant?

Depressive disorders are a common cause of chronic and recurrent psychiatric dysfunction, constituting the fourth leading cause of global diseases. Depression is associated with a high rate of morbidity and mortality, and is a leading cause of global disability. Despite the effectiveness of most currently available antidepressants, many of them have a number of undesirable side effects. Agomelatine is the first melatonin (MT)(1)/MT(2) agonist having 5-hydroxytryptamine (5-HT)(2C) and 5-HT(2B) antagonist properties and antidepressant activity. Agomelatine is effective in several animal models of depression and anxiety. In addition, three large, multicenter, multinational, placebo-controlled studies and several double-blind, placebo-controlled trials of agomelatine have demonstrated that it is a clinically effective and well-tolerated antidepressant in acute trials. Since currently available antidepressants are not always adequate to cause complete remission of symptoms in severely depressed patients, the superior rate of response achieved with agomelatine in this group of patients underlines its future for clinical use in depressive disorders. In summary, the clinical advantage of agomelatine is attributed to its novel mechanism of action, which helps not only to exert antidepressant action, but also to regulate the sleep-wake rhythm.

Use of transcranial magnetic stimulation of the brain in stroke rehabilitation

Preliminary studies suggest that stimulation of the motor cortex enhances motor recovery after stroke. Most of these studies employed transcranial magnetic stimulation of the brain and two different approaches have been evaluated. The first approach is based on the use of protocols of stimulation that increase cortical excitability, targeting the hemisphere in which the stroke occurred in order to enhance the output of the motor cortex and the response to physiotherapy. The second approach is based on the use of protocols of stimulation that suppress cortical excitability, targeting the intact hemisphere in order to counteract the imbalance due to the increased interhemispheric inhibition onto the lesioned cortex, and reducing the potential negative interference of the intact hemisphere with the function of the affected one. Cumulatively, preliminary studies suggest that transcranial magnetic stimulation might be a suitable method to combine with physiotherapy and improve recovery of useful limb function in stroke patients. However, further studies are needed to determine the best stimulation parameters and how to select patients who are likely to respond to this treatment.

Pharmacotherapy of pathological gambling: review of new treatment modalities

Pathological gambling is classified in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition as an impulse-control disorder. In the International Classification of Diseases of the WHO, pathological gambling is coded under the heading of 'Habit and Impulse Disorders'. Pathological gambling is a chronic, progressive disorder, which has a prevalence of 1-3.4% among western civilizations. The enormous personal and social consequences of this disorder include a high rate of suicide attempts, job loss, marital and family problems, legal problems, and criminal behavior. Recent studies have demonstrated that pathological gambling patients respond well to treatment with selective serotonin reuptake inhibitors, mood stabilizers and opioid antagonists. These findings support the idea that pathological gambling and other disorders of impulse control may be conceptualized as part of the obsessive-compulsive spectrum disorders or addictive disorders. This article will discuss possible treatment strategies according to different behavior patterns in pathological gambling and also remind the physicians who intend to treat this disorder of the possible diagnosis of pathological gambling.

New challenges in family interventions for schizophrenia

This review first outlines the rationale and research base supporting the development of family interventions for schizophrenia. The over-riding principles guiding effective family interventions for schizophrenia are then presented, along with the key components (engagement, assessment, education, communication skills training and problem-solving) shared by most family programs in schizophrenia. Meta-analyses demonstrating the efficacy of family interventions in reducing relapse and rehospitalization in schizophrenia are then discussed, along with issues regarding minimal duration of effective treatment, differential benefits of single and multiple family modalities and mixed evidence for the maintenance of treatment effects after termination. The benefits of participation in family-organized, nonprofessional support and education programs are then described. Finally, three issues meriting further study are outlined.

What research is being done on prenatal alcohol exposure and fetal alcohol spectrum disorders in the Russian research community?

AIMS

Although Russia has one of the highest rates of alcohol consumption and alcohol-attributable burden of disease, little is known about the existing research on prenatal alcohol exposure (PAE) and Fetal Alcohol Spectrum Disorders (FASDs) in this country. The objective of this study was to locate and review published and unpublished studies related to any aspect of PAE and FASD conducted in or using study populations from Russia.

METHODS

A systematic literature search was conducted in multiple English and Russian electronic bibliographic databases. In addition, a manual search was conducted in several major libraries in Moscow.

RESULTS

The search revealed a small pool of existing research studies related to PAE and/or FASD in Russia (126: 22 in English and 104 in Russian). Existing epidemiological data indicate a high prevalence of PAE and FASD, which underlines the strong negative impact that alcohol has on mortality, morbidity and disability in Russia. High levels of alcohol consumption by women of childbearing age, low levels of contraception use, and low levels of knowledge by health and other professionals regarding the harmful effects of PAE put this country at great risk of further alcohol-affected pregnancies.

CONCLUSIONS

Alcohol preventive measures in Russia warrant immediate attention. More research focused on alcohol prevention and policy is needed in order to reduce alcohol-related harm, especially in the field of FASD.

HSP90 inhibitors: current development and potential in cancer therapy

In the last decade, the molecular chaperone HSP90 has emerged as an important target in cancer therapeutics and has subsequently become the focus of several drug discovery and development efforts. The first-in-class HSP90 inhibitor 17-AAG entered into Phase I clinical trial in 1999. Today 13 HSP90 inhibitors representing multiple drug classes, with different modes of action, are undergoing clinical evaluation. The present review will highlight the involvement of HSP90 in regulating and maintaining the transformed phenotype, provide an overview on current HSP90 inhibitors and further update on the most relevant patents which have recently appeared in the literature.

New trial designs and potential therapies for pulmonary artery hypertension

A greater understanding of the epidemiology, pathogenesis, and pathophysiology of pulmonary artery hypertension (PAH) has led to significant advances, but the disease remains fatal. Treatment options are neither universally available nor always effective, underscoring the need for development of novel therapies and therapeutic strategies. Clinical trials to date have provided evidence of efficacy, but were limited in evaluating the scope and duration of treatment effects. Numerous potential targets in varied stages of drug development exist, in addition to novel uses of familiar therapies. The pursuit of gene and cell-based therapy continues, and device use to help acute deterioration and chronic management is emerging. This rapid surge of drug development has led to multicenter pivotal clinical trials and has resulted in novel ethical and global clinical trial concerns. This paper will provide an overview of the opportunities and challenges that await the development of novel treatments for PAH.

Evaluating many treatments and biomarkers in oncology: a new design

There is a pressing need for more-efficient trial designs for biomarker-stratified clinical trials. We suggest a new approach to trial design that links novel treatment evaluation with the concurrent evaluation of a biomarker within a confirmatory phase II/III trial setting. We describe a new protocol using this approach in advanced colorectal cancer called FOCUS4. The protocol will ultimately answer three research questions for a number of treatments and biomarkers: (1) After a period of first-line chemotherapy, do targeted novel therapies provide signals of activity in different biomarker-defined populations? (2) If so, do these definitively improve outcomes? (3) Is evidence of activity restricted to the biomarker-defined groups? The protocol randomizes novel agents against placebo concurrently across a number of different biomarker-defined population-enriched cohorts: BRAF mutation; activated AKT pathway: PI3K mutation/absolute PTEN loss tumors; KRAS and NRAS mutations; and wild type at all the mentioned genes. Within each biomarker-defined population, the trial uses a multistaged approach with flexibility to adapt in response to planned interim analyses for lack of activity. FOCUS4 is the first test of a protocol that assigns all patients with metastatic colorectal cancer to one of a number of parallel population-enriched, biomarker-stratified randomized trials. Using this approach allows questions regarding efficacy and safety of multiple novel therapies to be answered in a relatively quick and efficient manner, while also allowing for the assessment of biomarkers to help target treatment.

Predictors of older adults' technology use and its relationship to depressive symptoms and well-being

OBJECTIVE

To extend the empirical evidence regarding the predictors of older adults' use of information and communications technology (ICT) and to further examine its relationship to depressive symptoms and well-being.

METHOD

This cross-sectional study utilized a sample of community-dwelling older adults from the National Health and Aging Trends Study (N = 6,443). Structural equation modeling was used to estimate the effects of predictor variables on ICT use and the effects of use on depressive symptoms and well-being. Tests of moderation by demographic characteristics and level of ICT use were also performed.

RESULTS

Socioeconomic status (SES), age, and cognitive function accounted for approximately 60% of the variance in ICT use. SES was a stronger predictor for Blacks/African Americans, whereas cognitive function was a stronger predictor for Whites. ICT use was unrelated to depressive symptoms or well-being. However, it acted as a moderator, such that limitations in activities of daily living (ADLs) was a stronger predictor of depressive symptoms for high ICT users, whereas ill-health was a stronger predictor for non/limited users.

DISCUSSION

Findings do not support the claim that ICT use directly enhances mental health or well-being among older adults although it may protect against depressive symptoms for individuals coping with health conditions other than ADL impairments.

The evolving role of diffusion magnetic resonance imaging in movement disorders

Significant advances have allowed diffusion magnetic resonance imaging (MRI) to evolve into a powerful tool in the field of movement disorders that can be used to study disease states and connectivity between brain regions. Diffusion MRI is a promising potential biomarker for Parkinson's disease and other forms of parkinsonism, and may allow the distinction of different forms of parkinsonism. Techniques such as tractography have contributed to our current thinking regarding the pathophysiology of dystonia and possible mechanisms of penetrance. Diffusion MRI measures could potentially assist in monitoring disease progression in Huntington's disease, and in uncovering the nature of the processes and structures involved the development of essential tremor. The ability to represent structural connectivity in vivo also makes diffusion MRI an ideal adjunctive tool for the surgical treatment of movement disorders. We review recent studies using diffusion MRI in movement disorders research and present the current state of the science as well as future directions.

Autologous bone marrow-derived stem cell therapy in heart disease: discrepancies and contradictions

BACKGROUND

Autologous bone marrow stem cell therapy is the greatest advance in the treatment of heart disease for a generation according to pioneering reports. In response to an unanswered letter regarding one of the largest and most promising trials, we attempted to summarise the findings from the most innovative and prolific laboratory.

METHOD AND RESULTS

Amongst 48 reports from the group, there appeared to be 5 actual clinical studies ("families" of reports). Duplicate or overlapping reports were common, with contradictory experimental design, recruitment and results. Readers cannot always tell whether a study is randomised versus not, open-controlled or blinded placebo-controlled, or lacking a control group. There were conflicts in recruitment dates, criteria, sample sizes, million-fold differences in cell counts, sex reclassification, fractional numbers of patients and conflation of competitors' studies with authors' own. Contradictory results were also common. These included arithmetical miscalculations, statistical errors, suppression of significant changes, exaggerated description of own findings, possible silent patient deletions, fractional numbers of coronary arteries, identical results with contradictory sample sizes, contradictory results with identical sample sizes, misrepresented survival graphs and a patient with a negative NYHA class. We tabulate over 200 discrepancies amongst the reports. The 5 family-flagship papers (Strauer 2002, STAR, IACT, ABCD, BALANCE) have had 2665 citations. Of these, 291 citations were to the pivotal STAR or IACT-JACC papers, but 97% of their eligible citing papers did not mention any discrepancies. Five meta-analyses or systematic reviews covered these studies, but none described any discrepancies and all resolved uncertainties by undisclosed methods, in mutually contradictory ways. Meta-analysts disagreed whether some studies were randomised or "accepter-versus-rejecter". Our experience of presenting the discrepancies to journals is that readers may remain unaware of such problems.

CONCLUSIONS

Modern reporting of clinical research can still be imperfect. The scientific literature absorbs such reports largely uncritically. Even meta-analyses seem to resolve contradictions haphazardly. Discrepancies communicated to journals are not guaranteed to reach the scientific community. Journals could consider prioritising systematic reporting of queries even if seemingly minor, and establishing a policy of "habeas data".