Prolonged-Release vs Immediate-Release Tacrolimus Capsules in Black vs White Kidney Transplant Patients: A Post Hoc Analysis of Phase III Data

BACKGROUND

Black kidney transplant patients experience inferior outcomes compared with other ethnicities. Because scrutiny is required when immunosuppressant drugs are used in such at-risk populations, we report the first large-scale clinical efficacy data assessing prolonged-release tacrolimus (PR-T) in black de novo kidney transplant patients.

METHODS AND MATERIALS

We used logistic regression and proportionate hazards to compare a composite outcome measure (biopsy-proven acute rejection, graft loss, mortality, and loss to follow-up) in black and white patients in treatment groups longer than 24 weeks, from 3 large Phase III randomized controlled trials. Secondary endpoints included tacrolimus trough concentration, dose, and estimated glomerular filtration rate.

RESULTS

The study included 2162 patients whose treatments belonged to two categories (immediate-release tacrolimus: 77 black patients, 721 white patients; and PR-T: 87 black patients, 1277 white patients). Despite demographic factors generally predictive of worse outcomes, efficacy failure among black patients who received PR-T was non-inferior to that among white patients who received either therapy. Compared with immediate-release tacrolimus, black patients who received PR-T achieved stable tacrolimus concentrations 2.5 times faster (21 vs 56 days, P = .04), and more achieved stable target concentrations (76.7% vs 69.3%). Treatment-emergent adverse events were consistent with those reported separately in pivotal trials.

CONCLUSIONS

Overall, black patients who received PR-T achieved non-inferior outcomes compared to white patients, despite higher pretransplant risk among black patients. Moreover, PR-T improved the time to achieve, and the likelihood of reaching, stable therapeutic concentrations among black patients, suggesting that PR-T could improve the consistency of tacrolimus exposure in this patient population.

The Hemisection Approach in Large Animal Models of Spinal Cord Injury: Overview of Methods and Applications

Introduction: Translating basic science research into a safe and effective therapy for spinal cord injury (SCI) requires suitable large animal models for testing both implantable devices and biologic approaches to better approximate human anatomy and function. Hemisection lesions, routinely used for investigational purposes in small animals, are less frequently described in large animals that might be appropriate for translational studies. Size constraints of small animals (mice and rats) limits the predictability of the findings when scaled up. Our goal is to review the status of hemisection SCI in large animals across species and time to prepare for the testing of a novel intradural spinal cord stimulation device for control of spasticity in an ovine model. Methods and Results: We surveyed the literature on hemisection in quadrupeds and nonhuman primates, and catalogued the species, protocols and outcomes of the experimental work in this field. Feline, lapine, canine, simian, porcine, ovine and bovine models were the primary focal points. There is a consistent body of literature reporting use of the hemisection approach in large animals, but with differences in surgical technique depending on the goals and nature of the individual studies. While the injuries are not always consistent, the experimental variability is generally lower than that of the contusion-based approach. In general, as the body size of the animal increases, animal care requirements and the associated costs follow. In most cases, this is inversely correlated with the number of animals used in hemisection models. Conclusions: The hemisection approach to modeling SCI is straightforward compared with other methods such as the contusive impact and enables the transection of isolated ascending and descending tracts and segment specific cell bodies. This has certain advantages in models investigating post-injury axonal regrowth. However, this approach is not generally in line with the patho-physiologies encountered in SCI patients. Even so, the ability to achieve more control over the level of injury makes it a useful adjunct to contusive and ischemic approaches, and suggests a useful role in future translational studies.

Behavioral impact of return of genetic test results for complex disease: Systematic review and meta-analysis

OBJECTIVE

Advances in genomewide association studies have made possible the return of genetic risk results for complex diseases. Two concerns about these results are (a) negative psychological consequences and (b) viewing probabilistic results as deterministic, leading to misinterpretation and inappropriate decisions. The present study evaluates these concerns through a meta-analytic review of existing literature.

METHOD

Seventeen genetic testing studies of complex disease, including 1,171 participants and reporting 195 effects, 104 of which were unadjusted for covariates, were meta-analyzed under a random effects model. Diseases included Alzheimer's, cardiovascular and coronary heart disease, lung cancer, melanoma, thrombophilia, and type II diabetes. Six domains of behavioral-psychological reactions were examined.

RESULTS

Carriers showed significantly increased self-reported behavior change compared to noncarriers when assessed 6 months or later after results return (Hedges's g = .36, p = .019).

CONCLUSIONS

Return of genetic testing results for complex disease does not strongly impact self-reported negative behavior or psychological function of at-risk individuals. Return of results does appear to moderately increase self-reported healthy behavior in carriers, although research on objectively observed behavior change is needed. This is a growing area of research, with preliminary results suggesting potential positive implications of genetic testing for complex disease on behavior change. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Mediating pathways from childhood ADHD to adolescent tobacco and marijuana problems: roles of peer impairment, internalizing, adolescent ADHD symptoms, and gender

BACKGROUND

We examined whether increased risk for adolescent tobacco and marijuana problems associated with childhood ADHD is explained by key intermediary influences during adolescence and differs by gender.

METHODS

Longitudinal structural equation models examined mediating effects on problems with both substances (or each substance separately) through age-14 peer impairment, internalizing, and adolescent ADHD symptoms in two twin samples, prospectively assessed since age 11 (N = 2,164). Whether these mediators contributed beyond mediating effects of early-adolescent substance use was also considered. Twin difference analyses further illuminated which mediators might be potentially causal.

RESULTS

Direct effects of childhood ADHD on age-17 tobacco and marijuana problems (i.e., independent of included mediators) as well as effects of adolescent ADHD symptoms were significant only for females. By contrast, mediation by peer impairment, evident particularly for marijuana, was relatively stronger for males than females. Depression and anxiety were not prospectively associated with age-17 substance problems when earlier substance problems were considered. Consistent with causal influence of early substance use on later problems, monozygotic twins with more severe tobacco or marijuana problems at age 14 than their co-twins were also more likely to have substance problems later in adolescence.

CONCLUSIONS

Mediation through peer impairment, continued presence of ADHD symptoms, and early substance use may alter development so that childhood ADHD indirectly contributes to problems with tobacco and marijuana. Targeting gender-sensitive interventions prior to mid-adolescence, before these patterns become established, is essential.

The Use of Active Centre Acylation to Control the Pharmacokinetic Profile of a Recombinant Chimaeric Plasminogen Activator

Recombinant hybrid plasminogen activators consisting of the “A” chain of plasminogen linked to the “B” chain of t-PA that are inhibited rapidly by plasma protease inhibitors have recently been described (Robinson et al. Circulation 1992; 86: 548-552). We have now shown that following bolus administration of native hybrid to guinea pigs, fibrinolytic activity was cleared rapidly from the circulation. Active centre acylation appeared to protect the hybrid from inhibition and allowed material to circulate as potentially active species for prolonged periods. Clearance rates of a range of acyl derivatives of the hybrid were 7-35-fold slower than for native hybrid and 20-100-fold slower than for t-PA. Clearance rates were influenced markedly by deacylation rate, such that clearance half-life correlated well with deacylation halflife. We have thus shown that it is feasible to control the pharmacokinetic profile of a recombinant hybrid plasminogen activator over a wide range by selection of an appropriate acyl group for attachment to the active site. Such control is not possible with plasminogen activators that are cleared predominantly by mechanisms other than inhibition.

Problematic alcohol use and hippocampal volume in a female sample: disentangling cause from consequence using a co-twin control study design

BACKGROUND

Although there is extensive evidence that problematic alcohol use is associated with smaller hippocampal volume, the typical cross-sectional study design cannot determine whether hippocampal deviations reflect pre-existing liability toward problematic alcohol use or instead reflect an alcohol exposure-related effect. We used the co-twin control study design, which capitalizes upon differences within a twin pair in levels of drinking, to differentiate pre-existing liability from an effect of alcohol exposure.

METHODS

The sample included 100 female twins, prospectively assessed from ages 11 to 24. Problematic alcohol use was assessed dimensionally and included indicators of quantity, frequency, and density of alcohol use and intoxication. Hippocampal volume was assessed using magnetic resonance imaging.

RESULTS

Problematic alcohol use (proximal and cumulative) was associated with significantly smaller left and right hippocampal volume. Follow-up co-twin control analyses that partitioned individual-level alcohol effects into pre-existing, familial liability and non-shared alcohol exposure-related effects indicated that this association reflected alcohol exposure. Greater alcohol using twins had smaller hippocampal volume relative to lesser alcohol using co-twins, beyond effects of their shared genetic and environmental liability toward problematic alcohol use. Results held accounting for recent alcohol use, other substance use, externalizing and internalizing psychopathology, personality traits, trauma exposure, and menstrual phase.

CONCLUSIONS

The association between problematic alcohol use and smaller hippocampal volume likely reflects an alcohol exposure-related effect. Differentiating pre-existing brain deviations that confer risk for problematic alcohol use from those that reflect effects of alcohol on the brain will inform etiological models of addiction and further prevention and intervention efforts.

Interaction of a Plasmin A-Chain/t-PA B-Chain Hybrid Enzyme with Plasma Inhibitors In Vivo and In Vitro

A hybrid plasminogen activator consisting of the “A” chain of plasmin linked to the “B” chain of rt-PA was inhibited in vitro in human and guinea pig plasmas 4 to 5-fold more rapidly than its parent activator, two-chain t-PA. Using zymographic and autoradiographic techniques together with the use of immunodepleted plasma the major inhibitor was identified as aIpha-2-antiplasmin. The pharmacokinetic profile of the hybrid in guinea pigs was determined by two different methods: disappearance of fibrinolytic activity and removal of radiolabelled hybrid from the circulation. Fibrinolytic activity was cleared rapidly via inhibitory mechanisms, whilst radiolabelled material was cleared considerably more slowly due to the formation of hybrid-inhibitor complexes. When the active site of the hybrid was reversibly acylated inhibitory mechanisms were evaded and a prolonged pharmacokinetic profile of activity was observed.

Reciprocal Associations Between Eating Pathology and Parent-Daughter Relationships Across Adolescence: A Monozygotic Twin Differences Study

This prospective study explored longitudinal, bidirectional associations between eating pathology and perceptions of the parent-child relationship (i.e., parent-child regard and involvement) across adolescence. Specifically, this study examined whether twin differences in mother-daughter and father-daughter relationship problems emerged as a risk factor for, or outcome of, twin differences in eating pathology. By examining twin differences, this study explored associations between variables while controlling for shared environmental and genetic effects. A population-based sample of 446 monozygotic twin girls and their mothers completed questionnaires when twins were approximately 11, 14, and 17 years. Responses were analyzed using longitudinal cross-lagged models. Overall, few strong longitudinal associations were observed. Where longitudinal associations emerged, overall patterns indicated reciprocal associations that shifted across adolescence. Whereas twin differences in parent-daughter relationship variables more often predicted later twin differences in eating pathology across early adolescence, conversely, twin differences in eating pathology more often predicted later twin differences in parent-daughter relationship variables across later adolescence. In particular, the twin who reported greater eating pathology later reported more negative perceptions of the father-daughter relationship, as compared to her co-twin. Findings raise questions for future research regarding parental-in particular, paternal-responses to adolescent eating pathology and suggest the potential importance of efforts to support the parent-daughter relationship within the context of adolescent eating pathology.

Maladaptive personality traits and romantic relationship satisfaction: A monozygotic co-twin control analysis

The recent inclusion of an alternative model for personality disorders in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5; American Psychiatric Association, 2013a) highlights the importance of extreme variants of personality for psychopathology. The maladaptive personality traits described in the alternative model comprise 5 higher-order domains and 25 lower-order facets that capture pathological levels of personality. The present report adds to a growing body of research on the implications of maladaptive personality traits for functioning by demonstrating significant associations between each of the higher-order domains (Negative Affect, Detachment, Antagonism, Disinhibition, and Psychoticism) and most of the lower-order facets and lower romantic relationship satisfaction in a population-based sample of 284 monozygotic (MZ) adult twins. We further capitalized upon co-twin differences in levels of personality pathology in a causally informative approach, the MZ co-twin control study design. Co-twin control analyses indicated that higher levels of Negative Affect, Detachment, Disinhibition, and Psychoticism, as well as several lower-order facets, were associated with lower romantic relationship satisfaction even after accounting for the genetic and environmental factors shared by twins that confer liability toward personality pathology and psychosocial dysfunction. The present results lend support to the potentially causal implications of personality pathology for interpersonal functioning, even in a community sample unlikely to be evidencing clinical levels of pathology, by suggesting that extreme variants of personality, manifested by comparably extreme deviations in thinking, feeling, behaving, and interacting with others, may lead to impaired functioning in important domains. (PsycINFO Database Record

Pleomorphic liposarcoma of bone: a rare primary malignant bone tumour

BACKGROUND

Liposarcoma is an extremely rare primary bone sarcoma.

CASE PRESENTATION

We report a case of primary pleomorphic liposarcoma that arose in an 18 year old male in the metaphysis of the left tibia. Plain radiographs showed a partly sclerotic lesion and MR imaging a heterogeneous tumour predominantly isointense on T1- and high-signal on T2-weighted sequences with focal areas of increased T1 signal that suppressed with fat saturation. PET/CT showed marked FDG uptake (SUV = 17.1) in the primary tumour as well as a metastasis in the right distal femur and multiple small pulmonary metastases. Histologically, the tumour was a pleomorphic liposarcoma containing large tumour cells with vacuolated cytoplasm and hyperchromatic pleomorphic nuclei as well as numerous lipoblasts and scattered brown fat-like cells. Tumour cells strongly expressed FABP4/aP2, a marker of adipocyte differentiation, and UCP1, a marker of brown fat, but not S100. The case was treated with neoadjuvant MAP chemotherapy, resulting in extensive (> 95%) necrosis in the primary tumour and almost complete resolution of the femoral and pulmonary metastases.

CONCLUSIONS

Pleomorphic liposarcoma can present as a sclerotic primary malignant bone tumour; markers of adipose differentiation are useful in histological diagnosis and neoadjuvant MAP chemotherapy results in significant tumor necrosis.

Rumination, Excessive Reassurance Seeking, and Stress Generation Among Early Adolescent Girls

Nolen-Hoeksema proposed that rumination increases stressful events and circumstances; however, few studies have examined this question. Thus, we explored whether (a) rumination predicted increases in the generation of chronic and acute stress, (b) excessive reassurance seeking (ERS) mediated links between rumination and stress generation, (c) rumination increased exposure to acute independent (uncontrollable) stress, and (d) rumination predicted chronic stress generation in certain domains, but not others. These questions were examined in a 1-year study of 126 early adolescent girls ( M age = 12.39 years) using contextual objective stress interviews. Findings indicated that rumination predicted increases in acute dependent interpersonal stress and chronic interpersonal stress, and ERS mediated these associations. Moreover, rumination was not associated with acute independent stress. Finally, the effect of rumination on chronic stress generation was most salient in adolescents' romantic lives and in parent-adolescent relationships. These findings suggest that ruminators create stressful interpersonal environments.

PDE11A negatively regulates lithium responsivity

Lithium responsivity in patients with bipolar disorder has been genetically associated with Phosphodiesterase 11A (PDE11A), and lithium decreases PDE11A mRNA in induced pluripotent stem cell-derived hippocampal neurons originating from lithium-responsive patients. PDE11 is an enzyme uniquely enriched in the hippocampus that breaks down cyclic AMP and cyclic GMP. Here we determined whether decreasing PDE11A expression is sufficient to increase lithium responsivity in mice. In dorsal hippocampus and ventral hippocampus (VHIPP), lithium-responsive C57BL/6J and 129S6/SvEvTac mice show decreased PDE11A4 protein expression relative to lithium-unresponsive BALB/cJ mice. In VHIPP, C57BL/6J mice also show differences in PDE11A4 compartmentalization relative to BALB/cJ mice. In contrast, neither PDE2A nor PDE10A expression differ among the strains. The compartment-specific differences in PDE11A4 protein expression are explained by a coding single-nucleotide polymorphism (SNP) at amino acid 499, which falls within the GAF-B homodimerization domain. Relative to the BALB/cJ 499T, the C57BL/6J 499A decreases PDE11A4 homodimerization, which removes PDE11A4 from the membrane. Consistent with the observation that lower PDE11A4 expression correlates with better lithium responsiveness, we found that Pde11a knockout mice (KO) given 0.4% lithium chow for 3+ weeks exhibit greater lithium responsivity relative to wild-type (WT) littermates in tail suspension, an antidepressant-predictive assay, and amphetamine hyperlocomotion, an anti-manic predictive assay. Reduced PDE11A4 expression may represent a lithium-sensitive pathophysiology, because both C57BL/6J and Pde11a KO mice show increased expression of the pro-inflammatory cytokine interleukin-6 (IL-6) relative to BALB/cJ and PDE11A WT mice, respectively. Our finding that PDE11A4 negatively regulates lithium responsivity in mice suggests that the PDE11A SNPs identified in patients may be functionally relevant.

Is the number of new trauma and orthopaedic consultant posts increasing or decreasing?

Introduction Trauma and orthopaedics is a popular surgical specialty in the UK. Recent changes to the National Health Service have suggested an imbalance with fewer jobs yet more trainees. Furthermore, subspecialisation is emerging within all surgical disciplines. The aim of this study was to examine whether there were decreasing numbers of trauma and orthopaedic (T&O) consultant appointments in the UK, and to determine the frequency of subspecialisation. Methods All 51 issues of the British Medical Journal (BMJ) careers supplement from the year 2000 were reviewed as well as the 51 issues from 2010. The number of T&O posts, requested subspecialty interests and the number of posts in other surgical specialties were analysed. Results A total of 481 consultant posts in T&O were advertised in the 102 issues of the careers supplements reviewed. Of these, 281 were advertised in 2000 and 200 in 2010. The mean number of posts per issue was 5.5 in 2000 and 3.9 in 2010. In 2000 orthopaedic posts represented 30.5% of all surgical posts while in 2010 this was 37.8%. Under two-thirds (61.6%) of posts requested a specialty interest in 2000 but this increased to 93% in 2010. The greatest increase in named subspecialty was seen in 'spine' (from 4.1% to 19.0%.) while 'general' had the greatest decrease (from 38.4% to 7.0%). Conclusions UK consultant posts in T&O are decreasing in frequency. Most advertised posts request a subspecialty interest but registrar training focuses on producing 'generally' competent orthopaedic consultants. The onus is therefore on fellowships to develop subspecialty interest. As these are not all educationally approved, reconfiguration of fellowships is likely to be necessary.

Problematic alcohol use and reduced hippocampal volume: a meta-analytic review

BACKGROUND

A number of studies reports reduced hippocampal volume in individuals who engage in problematic alcohol use. However, the magnitude of the difference in hippocampal volume between individuals with v. without problematic alcohol use has varied widely, and there have been null findings. Moreover, the studies comprise diverse alcohol use constructs and samples, including clinically significant alcohol use disorders and subclinical but problematic alcohol use (e.g. binge drinking), adults and adolescents, and males and females.

METHODS

We conducted the first quantitative synthesis of the published empirical research on associations between problematic alcohol use and hippocampal volume. In total, 23 studies were identified and selected for inclusion in the meta-analysis; effects sizes were aggregated using a random-effects model.

RESULTS

Problematic alcohol use was associated with significantly smaller hippocampal volume (d = -0.53). Moderator analyses indicated that effects were stronger for clinically significant v. subclinical alcohol use and among adults relative to adolescents; effects did not differ among males and females.

CONCLUSIONS

Problematic alcohol use is associated with reduced hippocampal volume. The moderate overall effect size suggests the need for larger samples than are typically included in studies of alcohol use and hippocampal volume. Because the existing literature is almost entirely cross-sectional, future research using causally informative study designs is needed to determine whether this association reflects premorbid risk for the development of problematic alcohol use and/or whether alcohol has a neurotoxic effect on the hippocampus.