Fibrinogen/LDL apheresis is a promising rescue therapy for sudden sensorineural hearing loss

Randomized, placebo-controlled study on efficacy, safety and tolerability of drug-induced defibrinogenation for sudden sensorineural hearing loss: the lessons learned

PURPOSE

Disturbance of cochlear microcirculation is discussed as final common pathway of various inner ear diseases. Hyperfibrinogenemia causing increased plasma viscosity is a possible factor for a critical reduction of cochlear blood flow that might lead to sudden sensorineural hearing loss (SSHL). The aim was to determine the efficacy and safety of drug-induced defibrinogenation by ancrod for SSHL.

METHODS

Double-blind, randomized, placebo-controlled, multicenter, parallel group, phase II (proof-of-concept) study (planned enrollment: 99 patients). Patients received an infusion of ancrod or placebo (day 1) followed by subcutaneous administrations (day 2, 4, 6). Primary outcome was the change in pure tone audiogram air conduction average until day 8.

RESULTS

The study was terminated early due to slow recruiting (31 enrolled patients: 22 ancrod, 9 placebo). A significant improvement of hearing loss was registered in both groups (ancrod: - 14.3 dB ± 20.4 dB, - 39.9% ± 50.4%; placebo: - 22.3 dB ± 13.7 dB, - 59.1% ± 38.0%). A statistically significant group-difference was not detected (p = 0.374). Placebo response of 33.3% complete and 85.7% at least partial recovery was observed. Plasma fibrinogen levels were reduced significantly by ancrod (baseline: 325.2 mg/dL, day 2: 107.2 mg/dL). Ancrod was tolerated well, no adverse drug reaction was of severe intensity, no serious adverse events occurred.

CONCLUSION

Ancrod reduced fibrinogen levels that support its mechanism of action. The safety profile can be rated positively. Since the planned number of patients could not be enrolled, no efficacy conclusion can be drawn. The high rate of placebo response challenges clinical trials for SSHL and needs to be considered in future investigations. Trial registrations This study was registered in the EU Clinical Trials Register, EudraCT-No. 2012-000066-37 at 2012-07-02.

Association of inflammatory markers with hearing impairment: The English Longitudinal Study of Ageing

BACKGROUND

Hearing impairment is common at an older age and has considerable social, health and economic implications. With an increase in the ageing population, there is a need to identify modifiable risk factors for hearing impairment. A shared aetiology with cardiovascular disease (CVD) has been advanced as CVD risk factors (e.g. obesity, type 2 diabetes) are associated with a greater risk of hearing impairment. Moreover, low-grade inflammation is implicated in the aetiology of CVD. Accordingly, our aim was to investigate the association between several markers of inflammation - C-reactive protein, fibrinogen and white blood cell count - and hearing impairment.

METHODS

Participants of the English Longitudinal Study of Ageing aged 50-93 were included. Inflammatory marker data from both wave 4 (baseline, 2008/09) and wave 6 (2012/13) were averaged to measure systemic inflammation. Hearing acuity was measured with a simple handheld tone-producing device at follow-up (2014/15).

RESULTS

Among 4879 participants with a median age of 63 years at baseline, 1878 (38.4%) people presented hearing impairment at follow-up. All three biomarkers were positively and linearly associated with hearing impairment independent of age and sex. After further adjustment for covariates, including cardiovascular risk factors (smoking, physical activity, obesity, diabetes, hypertension, cholesterol), memory and depression, only the association with white blood cell count remained significant: odds ratio per log-unit increase; 95% confidence interval = 1.46; 1.11, 1.93.

CONCLUSIONS

While white blood cell count was positively associated with hearing impairment in older adults, no relationships were found for two other markers of low-grade inflammation.

Selected Blood Inflammatory and Metabolic Parameters Predicted Successive Bilateral Sudden Sensorineural Hearing Loss

Objectives

To explore whether peripheral inflammatory, metabolic, and hemostatic parameters could predict the pathogenesis of successive bilateral sudden sensorineural hearing loss (SSNHL).

Methods

This study reviewed 33 patients with successive bilateral SSNHL and 215 patients with unilateral SSNHL. Clinical characteristics and hematological parameters were compared, including the inflammatory markers (like neutrophil lymphocyte ratio (NLR), monocyte lymphocyte ratio (MLR), and platelet lymphocyte ratio (PLR)) and metabolic features (including hypertension, triglyceridemia, dyslipidemia, and hyperglycemia), as well as hemostatic indices (including prothrombin time (PT), activated partial thromboplastin time (APTT), and fibrinogen).

Results

In the successive bilateral SSNHL group, older average onset age (48.67 ± 15.36 vs. 42.71 ± 13.58, p < 0.05), higher male to female ratio (18 : 15 vs. 112 : 103, p > 0.05), and poorer therapeutic efficacy (12% vs. 59%, p < 0.01) were observed than those in the unilateral SSNHL group. Compared to the unilateral SSNHL group, NLR, MLR, and PLR in the successive bilateral SSNHL group were significantly higher (NLR: 5.72 ± 2.23 vs. 4.45 ± 2.82, p = 0.01; MLR: 0.25 ± 0.15 vs. 0.17 ± 0.11, p < 0.01; PLR: 190.70 ± 69.79 vs. 148.18 ± 65.67; p < 0.01); the LDL level was significantly higher; yet, the HDL level was significantly lower (LDL: 3.79 ± 0.53 vs. 3.49 ± 0.74; HDL: 1.33 ± 0.32 vs. 1.44 ± 0.26; p < 0.05 for both); fibrinogen was significantly higher (4.03 ± 0.47 vs. 3.70 ± 0.65; p < 0.01). Logistic regression analysis demonstrated that the risk factors for successive bilateral SSNHL included age, NLR, MLR, PLR, LDL, HDL, diabetes, and fibrinogen. However, only NLR, MLR, PLR, diabetes, LDL, and HDL independently predicted successive bilateral SSNHL.

Conclusion

Selected blood inflammatory markers combined with metabolic parameters were positively correlated with successive bilateral SSNHL.

Effect of statins on hearing function and subjective tinnitus in hyperlipidemic patients

INTRODUCTION

It is known that hyperlipidemia reduces hearing functions. In this study, we aimed to study the effect of antihyperlipidemic drugs on hearing functions and tinnitus.

METHODS

Eighty-four patients aged 18 to 84, who were diagnosed with hyperlipidemia and started treatment with the statin group (atorvastatin 20 mg and 40 mg, rosuvastatin 10 mg and 20 mg, and simvastatin 20 mg) of antihyperlipidemic drugs, were included in this study. All patients underwent pure-tone audiometry before starting treatment with antihyperlipidemic drugs. Patients with tinnitus were evaluated by Tinnitus Severity Index and Visual Analogue Scale. In the 6th month of therapy, otologic examination, pure-tone audiometry and tinnitus evaluation of the patients were repeated.

RESULTS

No significant difference was found in the pure-tone averages of the patients before and after statin use (p > 0.05). However, it was found in the audiometry that, after statin use, all drugs caused to statistically significant decrease in the hearing thresholds at 6000 Hertz (p < 0.05). Also, a strong increase was found in the Speech Discrimination percentages after treatment in patients using rosuvastatin 10 mg (p = 0.022). A significant decrease was found in the tinnitus frequency, duration, severity and degree of annoyance in patients using rosuvastatin 10 mg and 20 mg (p < 0.05).

CONCLUSION

Statin group of drugs can have a positive effect on the hearing functions and subjective tinnitus. In particular, it is seen that rosuvastatin group of statins has a more notable effect on tinnitus. It was considered that further studies with larger patient groups are needed.

[The etiopathogenetic aspects of idiopathic sensorineural impairment of hearing]

The objectives of the present work were the overview of the results of the modern investigations concerning etiology of idiopathic sensorineural impairment of hearing as well as the analysis of the theory of microthrombus formation and its role in pathogenesis of hearing impairment.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.

Quantitative Proteomics of Vestibular Schwannoma Cerebrospinal Fluid

This pilot study aimed to identify candidate proteins for future study that are differentially expressed in vestibular schwannoma (VS) cerebrospinal fluid (CSF) and to compare such proteins with those previously identified in perilymph and specimen secretions. CSF was collected intraoperatively prior to removal of untreated sporadic VS (3 translabyrinthine, 3 middle cranial fossa approaches) and compared with reference CSF samples. After proteolytic digestion and iTRAQ labeling, tandem mass spectrometry with ProteinPilot was used to identify candidate proteins. Of the 237 proteins detected, 13 were dysregulated in ≥3 of the 6 VS patients versus controls, and 13 were dysregulated (12 up, 1 down) in samples from patients with class D versus class B hearing. Four perilymph proteins of interest were dysregulated in ≥1 VS CSF samples. Thus, 26 candidate VS CSF biomarkers were identified that should be considered in future VS biomarker and tumor pathophysiology investigations.

High Total Cholesterol in Peripheral Blood Correlates with Poorer Hearing Recovery in Idiopathic Sudden Sensorineural Hearing Loss

Idiopathic sudden sensorineural hearing loss (ISSHL) is a common otologic emergency whose cause is still unclear. The importance of blood lipids in the pathogenesis of ISSHL is widely reported in literature. In fact elevated levels of low density lipoprotein cholesterol (LDL), total cholesterol (TC) and apolipoprotein B (Apo-B) have been proposed as risk factors for this pathology. No correlation has been described between serum lipid parameters and the prognosis of ISSHL. Aim of the present study was to identify prognostic factors associated with hearing recovery in a group of patients affected by ISSHL. Ninety-four patients with the diagnosis of ISSHL hospitalized between March 2013 and October 2014 were included in this study. Patients' blood sampling and hearing assessments were carried out. Patients were divided into two groups as "recovered" and "unrecovered", according to their response to the treatment. We found a statistically significant higher level of total cholesterol in the unrecovered group compared to the recovered one (p = 0.03). None of the other routine laboratory parameters have shown a statistically significant difference between the patients successfully treated and patients with poor outcomes. Total cholesterol concentrations may be a prognostic factor for recovery in ISSHL and should be assessed together with routine tests in patients with this condition. The other routine laboratory parameters seem to have no effect on the development and prognosis of this pathology.

High fibrinogen in peripheral blood correlates with poorer hearing recovery in idiopathic sudden sensorineural hearing loss

Objectives

We used hearing tests and peripheral blood sample analyses to characterize the pathology of idiopathic sudden sensorineural hearing loss (ISSNHL) and to identify possible prognostic factors for predicting recovery of hearing loss.

Study Design

A retrospective, multicenter trial was conducted.

Methods

Two hundred three patients examined within 7 days after the onset of ISSNHL received prednisone with lipo-prostaglandin E1. Pure-tone auditory tests were performed before and after treatment with these drugs. Blood tests were performed on blood samples collected during the patients’ initial visit to our clinic.

Results

In all patients, elevated white blood cell (WBC) counts, fasting blood sugar levels, HgbA1c, and erythrocyte sedimentation rate (ESR) significantly correlated with high hearing threshold measurements obtained on the initial visit. High fibrinogen levels, WBC counts, ESR, and low concentrations of fibrinogen degradation products (FDP) were associated with lower hearing recovery rates. Additionally, different audiogram shapes correlated with different blood test factors, indicating that different pathologies were involved.

Conclusions

High fibrinogen levels measured within seven days after ISSNHL onset correlated with poorer hearing recovery. This may be a consequence of ischemia or infections in the inner ear. The high WBC counts also observed may therefore reflect an immune response to inner ear damage induced by ischemic changes or infections. Our data indicate that therapeutic strategies should be selected based on the timing of initial treatment relative to ISSNHL onset.