Nigral stimulation for resistant axial motor impairment in Parkinson's disease? A randomized controlled trial

Gait and balance disturbances typically emerge in advanced Parkinson’s disease with generally limited response to dopaminergic medication and subthalamic nucleus deep brain stimulation. Therefore, advanced programming with interleaved pulses was put forward to introduce concomittant nigral stimulation on caudal contacts of a subthalamic lead. Here, we hypothesized that the combined stimulation of subthalamic nucleus and substantia nigra pars reticulata improves axial symptoms compared with standard subthalamic nucleus stimulation. Twelve patients were enrolled in this 2 × 2 cross-over double-blind randomized controlled clinical trial and both the safety and efficacy of combined subthalamic nucleus and substantia nigra pars reticulata stimulation were evaluated compared with standard subthalamic nucleus stimulation. The primary outcome measure was the change of a broad-scaled cumulative axial Unified Parkinson’s Disease Rating Scale score (Scale II items 13–15, Scale III items 27–31) at ‘3-week follow-up’. Secondary outcome measures specifically addressed freezing of gait, balance, quality of life, non-motor symptoms and neuropsychiatric symptoms. For the primary outcome measure no statistically significant improvement was observed for combined subthalamic nucleus and substantia nigra pars reticulata stimulation at the ‘3-week follow-up’. The secondary endpoints, however, revealed that the combined stimulation of subthalamic nucleus and substantia nigra pars reticulata might specifically improve freezing of gait, whereas balance impairment remained unchanged. The combined stimulation of subthalamic nucleus and substantia nigra pars reticulata was safe, and of note, no clinically relevant neuropsychiatric adverse effect was observed. Patients treated with subthalamic nucleus and substantia nigra pars reticulata stimulation revealed no ‘global’ effect on axial motor domains. However, this study opens the perspective that concomittant stimulation of the substantia nigra pars reticulata possibly improves otherwise resistant freezing of gait and, therefore, highly warrants a subsequent phase III randomized controlled trial.

Impact of sleep disorder treatment on fatigue in multiple sclerosis

BACKGROUND

We recently reported that sleep disorders are significantly associated with fatigue in multiple sclerosis (MS).

OBJECTIVE

The objective of this paper is to assess the effects of sleep disorder treatment on fatigue and related clinical outcomes in MS.

METHODS

This was a controlled, non-randomized clinical treatment study. Sixty-two MS patients completed standardized questionnaires including the Fatigue Severity Scale (FSS), Multidimensional Fatigue Inventory (MFI), Epworth Sleepiness scale (ESS) and Pittsburgh Sleep Quality Index (PSQI), and underwent polysomnography (PSG). Patients with sleep disorders were offered standard treatment. Fifty-six subjects repeated the questionnaires after ≥ three months, and were assigned to one of three groups: sleep disorders that were treated (SD-Tx, n=21), sleep disorders remaining untreated (SD-NonTx, n=18) and no sleep disorder (NoSD, n=17).

RESULTS

FSS and MFI general and mental fatigue scores improved significantly from baseline to follow-up in SD-Tx (p <0.03), but not SD-NonTx or NoSD subjects. ESS and PSQI scores also improved significantly in SD-Tx subjects (p <0.001). Adjusted multivariate analyses confirmed significant effects of sleep disorder treatment on FSS (-0.87, p = 0.005), MFI general fatigue score (p = 0.034), ESS (p = 0.042) and PSQI (p = 0.023).

CONCLUSION

Treatment of sleep disorders can improve fatigue and other clinical outcomes in MS.

A flavin binding cryptochrome photoreceptor responds to both blue and red light in Chlamydomonas reinhardtii

Cryptochromes are flavoproteins that act as sensory blue light receptors in insects, plants, fungi, and bacteria. We have investigated a cryptochrome from the green alga Chlamydomonas reinhardtii with sequence homology to animal cryptochromes and (6-4) photolyases. In response to blue and red light exposure, this animal-like cryptochrome (aCRY) alters the light-dependent expression of various genes encoding proteins involved in chlorophyll and carotenoid biosynthesis, light-harvesting complexes, nitrogen metabolism, cell cycle control, and the circadian clock. Additionally, exposure to yellow but not far-red light leads to comparable increases in the expression of specific genes; this expression is significantly reduced in an acry insertional mutant. These in vivo effects are congruent with in vitro data showing that blue, yellow, and red light, but not far-red light, are absorbed by the neutral radical state of flavin in aCRY. The aCRY neutral radical is formed following blue light absorption of the oxidized flavin. Red illumination leads to conversion to the fully reduced state. Our data suggest that aCRY is a functionally important blue and red light-activated flavoprotein. The broad spectral response implies that the neutral radical state functions as a dark form in aCRY and expands the paradigm of flavoproteins and cryptochromes as blue light sensors to include other light qualities.

Cyclin A1 shows age-related expression in benign tonsils, HPV16-dependent overexpression in HNSCC and predicts lower recurrence rate in HNSCC independently of HPV16

Background

Promoter methylation of the tumor suppressor gene Cyclin A1 could be associated with Human Papillomavirus 16 (HPV16) induced Head and Neck Squamous Cell Carcinoma (HNSCC) and Cervical Carcinoma. There is disagreement about the impact of this epigenetic event on protein expression of Cyclin A1 in malignant and non-malignant tissue and there hardly exists any information about possible relationships between Cyclin A1 expression and clinicopathological characteristics in HNSCC.

Methods

We analyzed protein expression of Cyclin A1 in 81 HNSCC and 74 benign tonsils by immunohistochemistry and correlated it to Cyclin A1 methylation status, presence of HPV16 infection and other clinicopathological characteristics.

Results

Overexpression of Cyclin A1 was more present in HNSCC than in tonsils (p < 0.001). In both entities, HNSCC and benign tonsils, expression of Cyclin A1 significantly correlated with the expression of Cyclin-dependent kinase-inhibitor p16 (p = 0.000672 and 0.00495). In tonsils, expression of Cyclin A1 was inversely proportional to age (p = 0.00000396), and further correlated with expression of tumor suppressor gene p53 (p = 0.000228). In HNSCC Cyclin A1 expression was associated with the presence of HPV16 DNA (p = 0.0014) and a lower recurrence rate in univariate and multivariate analysis (p = 0.002 and 0.013). Neither in HNSCC nor in tonsils Cyclin A1 expression correlated with promoter methylation.

Conclusions

Cyclin A1 is an important cell cycle regulator with age-related increased expression in tonsils of children. HPV16 induces overexpression of Cyclin A1 in HNSCC despite promoter methylation. Overexpression of Cyclin A1 predicts a lower recurrence rate in HNSCC independently of HPV16.

Deep-brain-stimulation does not impair deglutition in Parkinson's disease

OBJECTIVE

A large proportion of patients with Parkinson's disease develop dysphagia during the course of the disease. Dysphagia in Parkinson's disease affects different phases of deglutition, has a strong impact on quality of life and may cause severe complications, i.e., aspirational pneumonia. So far, little is known on how deep-brain-stimulation of the subthalamic nucleus influences deglutition in PD.

METHODS

Videofluoroscopic swallowing studies on 18 patients with Parkinson's disease, which had been performed preoperatively, and postoperatively with deep-brain-stimulation-on and deep-brain-stimulation-off, were analyzed retrospectively. The patients were examined in each condition with three consistencies (viscous, fluid and solid). The 'New Zealand index for multidisciplinary evaluation of swallowing (NZIMES) Subscale One' for qualitative and 'Logemann-MBS-Parameters' for quantitative evaluation were assessed.

RESULTS

Preoperatively, none of the patients presented with clinically relevant signs of dysphagia. While postoperatively, the mean daily levodopa equivalent dosage was reduced by 50% and deep-brain-stimulation led to a 50% improvement in motor symptoms measured by the UPDRS III, no clinically relevant influence of deep-brain-stimulation-on swallowing was observed using qualitative parameters (NZIMES). However quantitative parameters (Logemann scale) found significant changes of pharyngeal parameters with deep-brain-stimulation-on as compared to preoperative condition and deep-brain-stimulation-off mostly with fluid consistency.

CONCLUSION

In Parkinson patients without dysphagia deep-brain-stimulation of the subthalamic nucleus modulates the pharyngeal deglutition phase but has no clinically relevant influence on deglutition. Further studies are needed to test if deep-brain-stimulation is a therapeutic option for patients with swallowing disorders.

Abstract 760: A randomized, crossover, phase 1 study to evaluate the effect of a strong CYP3A4 inhibitor on tivantinib (ARQ 197) pharmacokinetics in healthy subjects

Background: Tivantinib is a selective, oral, non-ATP-competitive, small-molecule inhibitor of c-MET. In vitro data suggest that CYP2C19 and CYP3A4 are the major enzymes involved in tivantinib metabolism. Therefore, there is potential that CYP3A4 inhibitors may affect tivantinib pharmacokinetics (PK) leading to increased exposure. During the course of their disease, cancer patients receive multiple drugs, some of which may be strong CYP3A4 inhibitors. This open-label, 2-stage study evaluated the effect of ketoconazole, a strong inhibitor of CYP3A4, on tivantinib metabolism in adults with different CYP2C19 activity. Methods: Healthy adults (age 18 to 45 years) with no clinical conditions were eligible. In stage 1, healthy subjects who were either an extensive metabolizer (EM) or intermediate metabolizer (IM) based on CYP2C19 activity were randomized to 1 of 2 sequences, each consisting of two 8-day treatment periods under fed conditions with a 14-day washout between periods. In sequence 1, tivantinib (120 mg) was administered alone on day 4 of period 1 followed by ketoconazole (400 mg/day) with concomitant tivantinib (120 mg) on day 4 of period 2. The treatments were reversed in sequence 2. If there was no interaction, poor metabolizer (PM) subjects were to be analyzed in stage 2. Serial blood samples were collected for 96 hours after tivantinib administration, and area under the curve (AUC), maximum concentration (Cmax), and time to peak concentration (tmax) were calculated and statistically compared. Results: Sixteen subjects were randomized equally to 1 of 2 treatment sequences. When tivantinib was combined with ketoconazole, total exposure to tivantinib (AUC) was increased 2.1-fold and Cmax was increased 1.4-fold compared with tivantinib alone. Median tmax was similar for ketoconazole + tivantinib and tivantinib alone (4.75 vs 4.50 hours, respectively). Exposure to tivantinib was 2- to 3-fold higher in CYP2C19 IM subjects compared with CYP2C19 EM subjects, with or without ketoconazole. The median tmax for tivantinib was comparable for IM and EM subjects with or without ketoconazole (tivantinib, 4.50 vs 4.49 hours, respectively and ketoconazole + tivantinib, 5.00 vs 4.50 hours, respectively). A total of 10 adverse events (AEs) were reported in 5 subjects (31%); 4 AEs were considered related to ketoconazole and the remaining AEs were unrelated to study treatment. Two subjects discontinued the study because of elevated creatinine (related to ketoconazole) and elevated neutrophils (unrelated to treatment), respectively. Stage 2 assessment in CYP2C19 PM subjects was not performed. Conclusions: Concurrent administration of ketoconazole substantially increased tivantinib exposure. Therefore, caution should be exercised when strong CYP3A4 inhibitors are coadministered with tivantinib.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 760. doi:1538-7445.AM2012-760

Subthalamic nucleus stimulation restores the efferent cortical drive to muscle in parallel to functional motor improvement

Pathological synchronization in large-scale motor networks constitutes a pathophysiological hallmark of Parkinson's disease (PD). Corticomuscular synchronization in PD is pronounced in lower frequency bands (< 10 Hz), whereas efficient cortical motor integration in healthy persons is driven in the beta frequency range. Electroencephalogram and electromyogram recordings at rest and during an isometric precision grip task were performed in four perioperative sessions in 10 patients with PD undergoing subthalamic nucleus deep-brain stimulation: (i) 1 day before (D0); (ii) 1 day after (D1); (iii) 8 days after implantation of macroelectrodes with stimulation off (D8StimOff); and (iv) on (D8StimOn). Analyses of coherence and phase delays were performed in order to challenge the effects of microlesion and stimulation on corticomuscular coherence (CMC). Additionally, local field potentials recorded from the subthalamic nucleus on D1 allowed comprehensive mapping of motor-related synchronization in subthalamocortical and cerebromuscular networks. Motor performance improved at D8StimOn compared with D0 and D8StimOff paralleled by a reduction of muscular activity and CMC in the theta band (3.9-7.8 Hz) and by an increase of CMC in the low-beta band (13.7-19.5 Hz). Efferent motor cortical drives to muscle presented mainly below 10 Hz on D8StimOff that were suppressed on D8StimOn and occurred on higher frequencies from 13 to 45 Hz. On D1, coherence of the high-beta band (20.5-30.2 Hz) increased during movement compared with rest in subthalamomuscular and corticomuscular projections, whereas it was attenuated in subcorticocortical projections. The present findings lend further support to the concept of pathological network synchronization in PD that is beneficially modulated by stimulation.

Precise pH measuring of platelet concentrates containing additive solution--the impact of the temperature

BACKGROUND AND OBJECTIVES

  Blood gas analysers measuring pH at 37°C (pH37) are widely used for pH determination of platelet (PLT) concentrates (PCs). For reporting pH at 22°C (pH22), converting of pH37 using the correct conversion factor is mandatory. For PCs stored in PLT additive solution (PAS), such conversion factors are not yet widely available. We studied pH in samples of PCs with different PAS/plasma ratios during warming from 22 to 37°C.

MATERIALS AND METHODS

  We measured pH in 39 samples containing modified PAS-III (PAS-IIIM) with a plasma carryover of 20%, 30% or 40% or no PAS-IIIM. Differences between pH22 and pH37 (dpH) were compared within and between study groups. Correlation between pH22 and dpH was tested. Additional measurements in 33 samples with three different PLT counts were performed to study the influence of PLT count on dpH.

RESULTS

  pH22 and pH37 within each group and dpH or dpH/dT between study groups differed significantly. The dpH was 0·135 ± 0·040, 0·021 ± 0·009, 0·033 ± 0·011 and 0·048 ± 0·017 for samples containing 100%, 20%, 30% or 40% plasma, respectively. Correlation between dpH and pH22 was strong in 100% (r = 0·696, P < 0·001), weaker in 30% and 40% (r = 0·367, P = 0·022 and r = 0·345, P = 0·032, respectively) and not existing in 20% plasma (r = 0·153, P = 0·354). PLT count did not influence the dpH significantly.

CONCLUSION

  The dpH is dependent on different PAS-IIIM/plasma ratios and pH range. For precise reporting of pH22, the respective dpH must be used if converting is necessary. Preferably, the pH should be reported at 37°C or measured directly at 22°C.

Terahertz radiation driven chiral edge currents in graphene

We observe photocurrents induced in single-layer graphene samples by illumination of the graphene edges with circularly polarized terahertz radiation at normal incidence. The photocurrent flows along the sample edges and forms a vortex. Its winding direction reverses by switching the light helicity from left to right handed. We demonstrate that the photocurrent stems from the sample edges, which reduce the spatial symmetry and result in an asymmetric scattering of carriers driven by the radiation electric field. The developed theory based on Boltzmann's kinetic equation is in a good agreement with the experiment. We show that the edge photocurrents can be applied for determination of the conductivity type and the momentum scattering time of the charge carriers in the graphene edge vicinity.

Combined STN/SNr-DBS for the treatment of refractory gait disturbances in Parkinson's disease: study protocol for a randomized controlled trial

BACKGROUND

Severe gait disturbances in idiopathic Parkinson's disease (PD) are observed in up to 80% of all patients in advanced disease stages with important impact on quality of life. There is an unmet need for further symptomatic therapeutic strategies, particularly as gait disturbances generally respond unfavourably to dopaminergic medication and conventional deep brain stimulation of the subthalamic nucleus in advanced disease stages. Recent pathophysiological research pointed to nigro-pontine networks entrained to locomotor integration. Stimulation of the pedunculopontine nucleus is currently under investigation, however, hitherto remains controversial. The substantia nigra pars reticulata (SNr)--entrained into integrative locomotor networks--is pathologically overactive in PD. High-frequent stimulation of the substantia nigra pars reticulata preferentially modulated axial symptoms and therefore is suggested as a novel therapeutic candidate target for neuromodulation of refractory gait disturbances in PD.

METHODS

12 patients with idiopathic Parkinson's disease and refractory gait disturbances under best individual subthalamic nucleus stimulation and dopaminergic medication will be enroled into this double-blind 2 × 2 cross-over clinical trial. The treatment consists of two different stimulation settings using (i) conventional stimulation of the subthalamic nucleus [STNmono] and (ii) combined stimulation of distant electrode contacts located in the subthalamic nucleus and caudal border zone of STN and substantia nigra pars reticulata [STN+SNr]. The primary outcome measure is the change of the cumulative 'axial score' (UPDRS II items '13-15' and UPRDS III items '27-31') at three weeks of constant stimulation in either condition. Secondary outcome measures include specific scores on freezing of gait, balance function, quality of life, non-motor symptoms, and neuropsychiatric symptoms. The aim of the present trial is to investigate the efficacy and safety of a three week constant combined stimulation on [STN+SNr] compared to [STNmono]. The results will clarify, whether stimulation on nigral contacts additional to subthalamic stimulation will improve therapeutic response of otherwise refractory gait disturbances in PD.

TRIAL REGISTRATION

The trial was registered with the clinical trials register of http://www.clinicaltrials.gov (NCT01355835).

IKK-2 inhibitor TPCA-1 represses nasal epithelial inflammation in vitro

BACKGROUND

Nasal polyposis (NP) is considered a subgroup within chronic rhinosinusitis. NP can be further subdivided into aspirin sensitive- and aspirin tolerant types (ASNP/ ATNP). Although the true etiology of NP has not been identified so far, it is agreed that NP represents an inflammatory disease of the nasal mucosa. Alterations of cellular kinase activities including that of IKK-2 might play a role in this inflammatory process.

METHODS

Paraffin sections of ASNP, ATNP and controls were immunostained with Phospho-IkB-α antibody that detects the direct IKK-2 product (IkB-α. Intensity of epithelial staining was analysed semi-quantitatively by two independent observers. In cultured nasal polyp epithelial cells (NPECs) epithelial derived cytokines IL-8 and GRO α were induced by TNF-α or Staphylococcal supernatants and subsequently repressed by IKK-2 inhibitor TPCA-1.

RESULTS

Significant Phospho-IkB-α staining was observed in the nasal epithelium of ASNP compared to ATNP and controls suggesting strong IKK-2 activation in patients with ASNP in vivo. In vitro, pro-inflammatory cytokines IL-8 and GRO-α in NPECs were significantly repressed by TPCA-1.

CONCLUSION

IKK-2 activity is increased in the subgroup of ASNP. IL-8 and GRO-α responses were repressed by IKK-2 inhibitor TPCA-1 in vitro. IKK-2 inhibitors might represent a potential target for anti-inflammatory intervention in ASNP.

Proximity induced enhancement of the Curie temperature in hybrid spin injection devices

We investigate the increase of the Curie temperature T(C) in a lateral spin injection geometry where the ferromagnetic (Ga,Mn)As injector and detector contacts are capped by a thin iron film. Because of interlayer coupling between Fe and (Ga,Mn)As T(C) gets enhanced by nearly 100% for the thinnest (Ga,Mn)As films. The use of the proximity effect might pave the way for practical implementation of spintronic devices.