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Jae J, Li Y, Sun C, Allan A, Basmaji J, Chilton S, Simsam MH, Kao R, Owen A, Parry N, Priestap F, Rochwerg B, Smith S, Turgeon AF, Vogt K, Walser E, Iansavitchene A, Ball I. Preclinical Studies on Mechanisms Underlying the Protective Effects of Propranolol in Traumatic Brain Injury: A Systematic Review. J Neuroimmune Pharmacol 2024; 19:33. [PMID: 38900343 DOI: 10.1007/s11481-024-10121-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/21/2024] [Indexed: 06/21/2024]
Abstract
Traumatic brain injury (TBI) is a leading cause of mortality and morbidity amongst trauma patients. Its treatment is focused on minimizing progression to secondary injury. Administration of propranolol for TBI maydecrease mortality and improve functional outcomes. However, it is our sense that its use has not been universally adopted due to low certainty evidence. The literature was reviewed to explore the mechanism of propranolol as a therapeutic intervention in TBI to guide future clinical investigations. Medline, Embase, and Scopus were searched for studies that investigated the effect of propranolol on TBI in animal models from inception until June 6, 2023. All routes of administration for propranolol were included and the following outcomes were evaluated: cognitive functions, physiological and immunological responses. Screening and data extraction were done independently and in duplicate. The risk of bias for each individual study was assessed using the SYCLE's risk of bias tool for animal studies. Three hundred twenty-three citations were identified and 14 studies met our eligibility criteria. The data suggests that propranolol may improve post-TBI cognitive and motor function by increasing cerebral perfusion, reducing neural injury, cell death, leukocyte mobilization and p-tau accumulation in animal models. Propranolol may also attenuate TBI-induced immunodeficiency and provide cardioprotective effects by mitigating damage to the myocardium caused by oxidative stress. This systematic review demonstrates that propranolol may be therapeutic in TBI by improving cognitive and motor function while regulating T lymphocyte response and levels of myocardial reactive oxygen species. Oral or intravenous injection of propranolol following TBI is associated with improved cerebral perfusion, reduced neuroinflammation, reduced immunodeficiency, and cardio-neuroprotection in preclinical studies.
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Affiliation(s)
- James Jae
- Department of Medicine, Western University, London, ON, Canada
| | - Yilong Li
- Department of Microbiology and Immunology, Western University, London, ON, Canada
| | - Clara Sun
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Alison Allan
- Department of Anatomy and Cell Biology, Western University, London, ON, Canada
| | - John Basmaji
- Department of Medicine, Western University, London, ON, Canada
| | | | | | - Raymond Kao
- Department of Medicine, Western University, London, ON, Canada
- London Health Sciences Trauma Program, London, ON, Canada
- Office of Academic Military Medicine, Western University, London, ON, Canada
| | - Adrian Owen
- Brain and Mind Institute, Western University, London, ON, Canada
| | - Neil Parry
- London Health Sciences Trauma Program, London, ON, Canada
- Office of Academic Military Medicine, Western University, London, ON, Canada
- Department of Surgery, Western University, London, ON, Canada
| | - Fran Priestap
- London Health Sciences Trauma Program, London, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Shane Smith
- London Health Sciences Trauma Program, London, ON, Canada
- Office of Academic Military Medicine, Western University, London, ON, Canada
- Department of Surgery, Western University, London, ON, Canada
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Kelly Vogt
- London Health Sciences Trauma Program, London, ON, Canada
- Department of Surgery, Western University, London, ON, Canada
| | - Eric Walser
- Department of Medicine, Western University, London, ON, Canada
- Office of Academic Military Medicine, Western University, London, ON, Canada
| | - Alla Iansavitchene
- Health Sciences Library, London Health Sciences Center, London, ON, Canada
| | - Ian Ball
- Department of Medicine, Western University, London, ON, Canada.
- London Health Sciences Trauma Program, London, ON, Canada.
- Office of Academic Military Medicine, Western University, London, ON, Canada.
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.
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Dehghani M, Pourmontaseri H. Aetiology, risk factors and treatment of typical and atypical pressure ulcers in patients with traumatic brain injury: A narrative review. Int Wound J 2024; 21:e14788. [PMID: 38420873 PMCID: PMC10902764 DOI: 10.1111/iwj.14788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 02/02/2024] [Indexed: 03/02/2024] Open
Abstract
Pressure ulcers are one of the leading complications in bedridden patients that result in multiple burdens on healthcare systems and patients (11 billion dollars/year). The prevalence of pressure ulcers in traumatic brain injury patients is 1.5-fold compared with the other bedridden patients. Moreover, critical traumatic brain injury patients who are admitted to the intensive care unit experience severe pressure ulcers and further complications. The motor/sensory disabilities and low supplementation and oxygenation to the pressured side were the main mechanisms of the typical pressure ulcers. Intellectual evaluation is the first essential step to prevent the development of pressure ulcers in high-risk patients. Till now, different scales, including Injury Scale Score and Braden Scale Score, have been provided to assess the pressure ulcer. Since low stages of pressure ulcers heal rapidly, traumatic brain injury patients require a periodical assessment to prevent further developments timely. Alongside different procedures provided to prevent and treat any pressure ulcer, traumatic brain injury patients required additional specific protections. For the first line, fast and efficient rehabilitation repairs motor/sensory disabilities and decreases the chance of pressure ulcer. Our review indicated that pressure ulcer in traumatic brain injury had several complex mechanisms that demand special care. Therefore, further studies are required to address these mechanisms and prevent their progression to typical and atypical pressure ulcers.
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Affiliation(s)
- Mohammadreza Dehghani
- Student Research Committee, Fasa University of Medical SciencesFasaIran
- Projects Support Division, Medical Students AssociationFasa University of Medical SciencesFasaIran
| | - Hossein Pourmontaseri
- Student Research Committee, Fasa University of Medical SciencesFasaIran
- Projects Support Division, Medical Students AssociationFasa University of Medical SciencesFasaIran
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Kodali M, Jankay T, Shetty AK, Reddy DS. Pathophysiological basis and promise of experimental therapies for Gulf War Illness, a chronic neuropsychiatric syndrome in veterans. Psychopharmacology (Berl) 2023; 240:673-697. [PMID: 36790443 DOI: 10.1007/s00213-023-06319-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 01/17/2023] [Indexed: 02/16/2023]
Abstract
This article describes the pathophysiology and potential treatments for Gulf War Illness (GWI), which is a chronic neuropsychiatric illness linked to a combination of chemical exposures experienced by service personnel during the first Gulf War in 1991. However, there is currently no effective treatment for veterans with GWI. The article focuses on the current status and efficacy of existing therapeutic interventions in preclinical models of GWI, as well as potential perspectives of promising therapies. GWI stems from changes in brain and peripheral systems in veterans, leading to neurocognitive deficits, as well as physiological and psychological effects resulting from multifaceted changes such as neuroinflammation, oxidative stress, and neuronal damage. Aging not only renders veterans more susceptible to GWI symptoms, but also attenuates their immune capabilities and response to therapies. A variety of experimental models are being used to investigate the pathophysiology and develop therapies that have the ability to alleviate devastating symptoms. Over two dozen therapeutic interventions targeting neuroinflammation, mitochondrial dysfunction, neuronal injury, and neurogenesis are being tested, including agents such as curcumin, curcumin nanoparticles, monosodium luminol, melatonin, resveratrol, fluoxetine, rolipram, oleoylethanolamide, ketamine, levetiracetam, nicotinamide riboside, minocycline, pyridazine derivatives, and neurosteroids. Preclinical outcomes show that some agents have promise, including curcumin, resveratrol, and ketamine, which are being tested in clinical trials in GWI veterans. Neuroprotectants and other compounds such as monosodium luminol, melatonin, levetiracetam, oleoylethanolamide, and nicotinamide riboside appear promising for future clinical trials. Neurosteroids have been shown to have neuroprotective and disease-modifying properties, which makes them a promising medicine for GWI. Therefore, accelerated clinical studies are urgently needed to evaluate and launch an effective therapy for veterans displaying GWI.
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Affiliation(s)
- Maheedhar Kodali
- Institute for Regenerative Medicine, Department of Molecular and Cellular Medicine, Texas A&M University School of Medicine, College Station, TX, USA
| | - Tanvi Jankay
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, TX, USA
| | - Ashok K Shetty
- Institute for Regenerative Medicine, Department of Molecular and Cellular Medicine, Texas A&M University School of Medicine, College Station, TX, USA.,Texas A&M Health Institute of Pharmacology and Neurotherapeutics, Texas A&M University Health Science Center, 8447 Riverside Pkwy, Bryan, TX, 77807, USA
| | - Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University School of Medicine, Bryan, TX, USA. .,Texas A&M Health Institute of Pharmacology and Neurotherapeutics, Texas A&M University Health Science Center, 8447 Riverside Pkwy, Bryan, TX, 77807, USA.
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Pilipović I, Stojić-Vukanić Z, Leposavić G. Adrenoceptors as potential target for add-on immunomodulatory therapy in multiple sclerosis. Pharmacol Ther 2023; 243:108358. [PMID: 36804434 DOI: 10.1016/j.pharmthera.2023.108358] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 02/03/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023]
Abstract
This review summarizes recent findings related to the role of the sympathetic nervous system (SNS) in pathogenesis of multiple sclerosis (MS) and its commonly used experimental model - experimental autoimmune encephalomyelitis (EAE). They indicate that noradrenaline, the key end-point mediator of the SNS, acting through β-adrenoceptor, has a contributory role in the early stages of MS/EAE development. This stage is characterized by the SNS hyperactivity (increased release of noradrenaline) reflecting the net effect of different factors, such as the disease-associated inflammation, stress, vitamin D hypovitaminosis, Epstein-Barr virus infection and dysbiosis. Thus, the administration of propranolol, a non-selective β-adrenoceptor blocker, readily crossing the blood-brain barrier, to experimental rats before the autoimmune challenge and in the early (preclinical/prodromal) phase of the disease mitigates EAE severity. This phenomenon has been ascribed to the alleviation of neuroinflammation (due to attenuation of primarily microglial activation/proinflammatory functions) and the diminution of the magnitude of the primary CD4+ T-cell autoimmune response (the effect associated with impaired autoantigen uptake by antigen presenting cells and their migration into draining lymph nodes). The former is partly related to breaking of the catecholamine-dependent self-amplifying microglial feed-forward loop and the positive feedback loop between microglia and the SNS, leading to down-regulation of the SNS hyperactivity and its enhancing influence on microglial activation/proinflammatory functions and the magnitude of autoimmune response. The effects of propranolol are shown to be more prominent in male EAE animals, the phenomenon important as males (like men) are likely to develop clinically more severe disease. Thus, these findings could serve as a firm scientific background for formulation of a new sex-specific immune-intervention strategy for the early phases of MS (characterized by the SNS hyperactivity) exploiting anti-(neuro)inflammatory and immunomodulatory properties of propranolol and other relatively cheap and safe adrenergic drugs with similar therapeutic profile.
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Affiliation(s)
- Ivan Pilipović
- Institute of Virology, Vaccines and Sera "Torlak", Belgrade, Serbia
| | - Zorica Stojić-Vukanić
- University of Belgrade-Faculty of Pharmacy, Department of Microbiology and Immunology, Belgrade, Serbia
| | - Gordana Leposavić
- University of Belgrade-Faculty of Pharmacy, Department of Pathobiology, Belgrade, Serbia.
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Wang X, Li X, Ma L, Chen H, You C. Pharmacological components with neuroprotective effects in the management of traumatic brain injury: evidence from network meta-analysis. Neurol Sci 2023; 44:1665-1678. [PMID: 36642741 DOI: 10.1007/s10072-023-06600-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/31/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Neuroprotective drugs have been used to prevent secondary brain injury in patients with traumatic brain injury; however, the optimal medication remains questionable. We performed a Bayesian network meta-analysis to evaluate the safety and efficacy of different medications with known neuroprotective properties in this group of patients. METHODS Several databases were searched to identify any eligible trials comparing pharmacological components with confirmed neuroprotective mechanisms. Bayesian network meta-analysis was performed to combine direct and indirect evidence. The surface under the cumulative ranking curve was obtained to determine the ranking probability of the treatment agents for each outcome. The primary outcome was all-cause mortality. RESULTS A total of 23 trials comprising 4,325 participants were identified. The pooled relative risk (RR) showed administration of erythropoietin (RR: 0.68; 95% CrI: 0.50-0.93) and propranolol (RR: 0.43; 95% CrI: 0.20-0.85) decreased all-cause mortality compared with placebo. We also found erythropoietin (RR: 1.55; 95% CrI: 1.03-2.35), propranolol (RR: 1.52; 95% CrI: 1.05-2.20), and progesterone (RR: 1.47; 95% CrI: 1.03-2.10) showed better efficacy in functional recovery. CONCLUSION Overall, erythropoietin and propranolol were associated with reduced mortality in adults with traumatic brain injury. These treatment agents were also associated with improved functional outcomes.
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Affiliation(s)
- Xing Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Xiaolong Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Hui Chen
- Department of Neurosurgery, Sichuan Friendship Hospital, Chengdu, Sichuan, People's Republic of China.
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
- West China Brain Research Centre, Sichuan University, Chengdu, Sichuan, People's Republic of China.
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A nationwide analysis on the interaction between frailty and beta-blocker therapy in hip fracture patients. Eur J Trauma Emerg Surg 2023; 49:1485-1497. [PMID: 36633610 DOI: 10.1007/s00068-023-02219-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/31/2022] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Hip fracture patients, who are often frail, continue to be a challenge for healthcare systems with a high postoperative mortality rate. While beta-blocker therapy (BBt) has shown a strong association with reduced postoperative mortality, its effect in frail patients has yet to be determined. This study's aim is to investigate how frailty, measured using the Orthopedic Hip Frailty Score (OFS), modifies the effect of preadmission beta-blocker therapy on mortality in hip fracture patients. METHODS This retrospective register-based study included all adult patients in Sweden who suffered a traumatic hip fracture and subsequently underwent surgery between 2008 and 2017. Treatment effect was evaluated using the absolute risk reduction (ARR) in 30-day postoperative mortality when comparing patients with (BBt+) and without (BBt-) ongoing BBt. Inverse probability of treatment weighting (IPTW) was used to reduce potential confounding when examining the treatment effect. Patients were stratified based on their OFS (0, 1, 2, 3, 4 and 5) and the treatment effect was also assessed within each stratum. RESULTS A total of 127,305 patients were included, of whom 39% had BBt. When IPTW was performed, there were no residual differences in observed baseline characteristics between the BBt+ and BBt- groups, across all strata. This analysis found that there was a stepwise increase in the ARRs for each additional point on the OFS. Non-frail BBt+ patients (OFS 0) exhibited an ARR of 2.2% [95% confidence interval (CI) 2.0-2.4%, p < 0.001], while the most frail BBt+ patients (OFS 5) had an ARR of 24% [95% CI 18-30%, p < 0.001], compared to BBt- patients within the same stratum. CONCLUSION Beta-blocker therapy is associated with a reduced risk of 30-day postoperative mortality in frail hip fracture patients, with a greater effect being observed with higher Orthopedic Hip Frailty Scores.
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Baucom MR, Wallen TE, Singer KE, Youngs J, Schuster RM, Blakeman TC, McGuire JL, Strilka R, Goodman MD. Postinjury Treatment to Mitigate the Effects of Aeromedical Evacuation After TBI in a Porcine Model. J Surg Res 2022; 279:352-360. [PMID: 35810552 DOI: 10.1016/j.jss.2022.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 04/14/2022] [Accepted: 05/21/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Early aeromedical evacuation after traumatic brain injury (TBI) has been associated with worse neurologic outcomes in murine studies and military populations. The goal of this study was to determine if commonly utilized medications, including allopurinol, propranolol, or tranexamic acid (TXA), could mitigate the secondary traumatic brain injury experienced during the hypobaric and hypoxic environment of aeromedical evacuation. METHODS Porcine TBI was induced via controlled cortical injury. Twenty nonsurvival pigs were separated into four groups (n = 5 each): TBI+25 mL normal saline (NS), TBI+4 mg propranolol, TBI+100 mg allopurinol, and TBI+1g TXA. The pigs then underwent simulated AE to an altitude of 8000 ft for 4 h with an SpO2 of 82-85% and were sacrificed 4 h later. Hemodynamics, serum cytokines, and hippocampal p-tau accumulation were assessed. An additional survival cohort was partially completed with TBI/NS (n = 5), TBI/propranolol (n = 2) and TBI/allopurinol groups (n = 2) survived to postinjury day 7. RESULTS There were no significant differences in hemodynamics, tissue oxygenation, cerebral blood flow, or physiologic markers between treatment groups and saline controls. Transient differences in IL-1b and IL-6 were noted but did not persist. Neurological Severity Score (NSS) was significantly lower in the TBI + allopurinol group on POD one compared to NS and propranolol groups. P-tau accumulation was decreased in the nonsurvival animals treated with allopurinol and TXA compared to the TBI/NS group. CONCLUSIONS Allopurinol, propranolol, and TXA, following TBI, do not induce adverse changes in systemic or cerebral hemodynamics during or after a simulated postinjury flight. While transient changes were noted in systemic cytokines and p-tau accumulation, further investigation will be needed to determine any persistent neurological effects of injury, flight, and pharmacologic treatment.
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Affiliation(s)
- Matthew R Baucom
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Taylor E Wallen
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | - Jackie Youngs
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | | | | | - Richard Strilka
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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Hicks SD, Leddy J, Lichak BP, Onks C, Dretsch M, Tennant P, Haider MN, Olympia RP, Zuckerman SL, Loeffert J, Loeffert AC, Monteith C, Master CL. Defining Biological Phenotypes of Mild Traumatic Brain Injury Using Saliva MicroRNA Profiles. J Neurotrauma 2022; 39:923-934. [PMID: 35412857 PMCID: PMC9248343 DOI: 10.1089/neu.2022.0018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Concussion is a heterogeneous injury that relies predominantly on subjective symptom reports for patient assessment and treatment. Developing an objective, biological test could aid phenotypic categorization of concussion patients, leading to advances in personalized treatment. This prospective multi-center study employed saliva micro-ribonucleic acid (miRNA) levels to stratify 251 individuals with concussion into biological subgroups. Using miRNA biological clusters, our objective was to assess for differences in medical/demographic characteristics, symptoms, and functional measures of balance and cognition. The miRNAs that best defined each cluster were used to identify physiological pathways that characterized each cluster. The 251 participants (mean age: 18 ± 7 years; 57% male) were optimally grouped into 10 clusters based on 22 miRNA levels. The clusters differed in age (χ2 = 19.1, p = 0.024), days post-injury at the time of saliva collection (χ2 = 22.6; p = 0.007), and number of prior concussions (χ2 = 17.6, p = 0.040). The clusters also differed in symptom reports for fatigue (χ2 = 17.7; p = 0.039), confusion (χ2 = 22.3; p = 0.008), difficulty remembering (χ2 = 22.0; p = 0.009), and trouble falling asleep (χ2 = 17.2; p = 0.046), but not objective balance or cognitive performance (p > 0.05). The miRNAs that defined concussion clusters regulate 16 physiological pathways, including adrenergic signaling, estrogen signaling, fatty acid metabolism, GABAergic signaling, synaptic vesicle cycling, and transforming growth factor (TGF)-β signaling. These results show that saliva miRNA levels may stratify individuals with concussion based on underlying biological perturbations that are relevant to both symptomology and pharmacological targets. If validated in a larger cohort, miRNA assessment could aid individualized, biology-driven concussion treatment.
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Affiliation(s)
- Steven D. Hicks
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - John Leddy
- Department of Sports Medicine, SUNY Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Department of Orthopedics, State University of New York at Buffalo, Buffalo, New York, USA
| | - Brooke P. Lichak
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Cayce Onks
- Department of Family Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
- Department of Orthopaedics and Rehabilitation, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Michael Dretsch
- US Army Medical Research Directorate-West, Walter Reed Army Institute of Research, Joint Base Lewis-McChord, Washington, USA
| | | | - Mohammad Nadir Haider
- Department of Sports Medicine, SUNY Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Department of Orthopedics, State University of New York at Buffalo, Buffalo, New York, USA
| | - Robert P. Olympia
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania, USA
- Department of Emergency Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Scott L. Zuckerman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jayson Loeffert
- Department of Family Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
- Department of Orthopaedics and Rehabilitation, College of Medicine, Penn State University, Hershey, Pennsylvania, USA
| | - Andrea C. Loeffert
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Chuck Monteith
- Department of Sports Medicine, Colgate University, Hamilton, New York, USA
| | - Christina L. Master
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Michalovicz LT, Kelly KA, Miller DB, Sullivan K, O'Callaghan JP. The β-adrenergic receptor blocker and anti-inflammatory drug propranolol mitigates brain cytokine expression in a long-term model of Gulf War Illness. Life Sci 2021; 285:119962. [PMID: 34563566 PMCID: PMC9047058 DOI: 10.1016/j.lfs.2021.119962] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 09/09/2021] [Accepted: 09/11/2021] [Indexed: 12/03/2022]
Abstract
Aims: Growing evidence suggests that Gulf War Illness (GWI) is the result of underlying neuroimmune dysfunction. For example, previously we found that several GWI-relevant organophosphate acetylcholinesterase inhibitors produce heightened neuroinflammatory responses following subchronic exposure to stress hormone as a mimic of high physiological stress. The goal of the current study was to evaluate the potential for the β-adrenergic receptor inhibitor and anti-inflammatory drug, propranolol, to treat neuroinflammation in a novel long-term mouse model of GWI. Main methods: Adult male C57BL/6J mice received a subchronic exposure to corticosterone (CORT) at levels mimicking high physiological stress followed by exposure to the sarin surrogate, diisopropyl fluorophosphate (DFP). These mice were then re-exposed to CORT every other week for a total of five weeks, followed by a systemic immune challenge with lipopolysaccharide (LPS). Animals receiving the propranolol treatment were given a single dose (20 mg/kg, i.p.) either four or 11 days prior to the LPS challenge. The potential anti-neuroinflammatory effects of propranolol were interrogated by analysis of cytokine mRNA expression. Key findings: We found that our long-term GWI model produces a primed neuroinflammatory response to subsequent immune challenge that is dependent upon GWI-relevant organophosphate exposure. Propranolol treatment abrogated the elaboration of inflammatory cytokine mRNA expression in the brain instigated in our model, having no treatment effects in non-DFP exposed groups. Significance: Our results indicate that propranolol may be a promising therapy for GWI with the potential to treat the underlying neuroinflammation associated with the illness.
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Affiliation(s)
- Lindsay T Michalovicz
- Health Effects Laboratory Division, Centers for Disease Control and Prevention-National Institute for Occupational Safety and Health, Morgantown, WV, USA
| | - Kimberly A Kelly
- Health Effects Laboratory Division, Centers for Disease Control and Prevention-National Institute for Occupational Safety and Health, Morgantown, WV, USA
| | - Diane B Miller
- Health Effects Laboratory Division, Centers for Disease Control and Prevention-National Institute for Occupational Safety and Health, Morgantown, WV, USA
| | | | - James P O'Callaghan
- Health Effects Laboratory Division, Centers for Disease Control and Prevention-National Institute for Occupational Safety and Health, Morgantown, WV, USA.
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Ding H, Liao L, Zheng X, Wang Q, Liu Z, Xu G, Li X, Liu L. β-Blockers for traumatic brain injury: A systematic review and meta-analysis. J Trauma Acute Care Surg 2021; 90:1077-1085. [PMID: 33496547 DOI: 10.1097/ta.0000000000003094] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Paroxysmal sympathetic hyperactivity (PSH) and catecholamine surge, which are associated with poor outcome, may be triggered by traumatic brain injury (TBI).β Adrenergic receptor blockers (β-blockers), as potential therapeutic agents to prevent paroxysmal sympathetic hyperactivity and catecholamine surge, have been shown to improve survival after TBI. The principal aim of this study was to investigate the effect of β-blockers on outcomes in patients with TBI. METHODS For this systematic review and meta-analysis, we searched MEDLINE, EMBASE, and Cochrane Library databases from inception to September 25, 2020, for randomized controlled trials, nonrandomized controlled trials, and observational studies reporting the effect of β-blockers on the following outcomes after TBI: mortality, functional measures, and cardiopulmonary adverse effects of β-blockers (e.g., hypotension, bradycardia, and bronchospasm). With use of random-effects model, we calculated pooled estimates, confidence intervals (CIs), and odds ratios (ORs) of all outcomes. RESULTS Fifteen studies with 12,721 patients were included. Exposure to β-blockers after TBI was associated with a significant reduction in adjusted in-hospital mortality (OR, 0.39; 95% CI, 0.30-0.51; I2 = 66.3%; p < 0.001). β-Blockers significantly improved the long-term (≥6 months) functional outcome (OR, 1.75; 95% CI, 1.09-2.80; I2 = 0%; p = 0.02). Statistically significant difference was not seen for cardiopulmonary adverse events (OR, 0.91; 95% CI, 0.55-1.50; I2 = 25.9%; p = 0.702). CONCLUSION This meta-analysis demonstrated that administration of β-blockers after TBI was safe and effective. Administration of β-blockers may therefore be suggested in the TBI care. However, more high-quality trials are needed to investigate the use of β-blockers in the management of TBI. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.
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Affiliation(s)
- Huaqiang Ding
- From the Department of Neurosurgery (H.D., Z.L.), Chongqing Yubei District People's Hospital; Department of Neurosurgery (L. Liao), Nan'an District People's Hospital of Chongqing, Chongqing; Department of Neurosurgery (Q.W.), People's Hospital of Hejiang City; Department of Neurosurgery (L. Liao, G.X., X.L., L. Liu), and Department of Neurology (X.Z.), Affiliated Hospital of Southwest Medical University; Neurosurgery Clinical Medical Research Center of Sichuan Province (L. Liu); Academician (Expert) Workstation of Sichuan Province (L. Liu); and Neurological Diseases and Brain Function Laboratory (L. Liu), Luzhou, China
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11
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Mitigating the stress response to improve outcomes for older patients undergoing emergency surgery with the addition of beta-adrenergic blockade. Eur J Trauma Emerg Surg 2021; 48:799-810. [PMID: 33847766 PMCID: PMC9001541 DOI: 10.1007/s00068-021-01647-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/11/2021] [Indexed: 12/14/2022]
Abstract
As population age, healthcare systems and providers are likely to experience a substantial increase in the proportion of elderly patients requiring emergency surgery. Emergency surgery, compared with planned surgery, is strongly associated with increased risks of adverse postoperative outcomes due to the short time available for diagnosis, optimization, and intervention in patients presenting with physiological derangement. These patient populations, who are often frail and burdened with a variety of co-morbidities, have lower reserves to deal with the stress of the acute condition and the required emergency surgical intervention. In this review article, we discuss topical areas where mitigation of the physiological stress posed by the acute condition and asociated surgical intervention may be feasible. We consider the impact of the adrenergic response and use of beta blockers for these high-risk patients and discuss common risk factors such as frailty and delirium. A proactive multidisciplinary approach to peri-operative care aimed at mitigation of the stress response and proactive management of common conditions in the older emergency surgical patient could yield more favorable outcomes.
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12
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Doxycycline improves traumatic brain injury outcomes in a murine survival model. J Trauma Acute Care Surg 2020; 89:435-440. [DOI: 10.1097/ta.0000000000002801] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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13
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Propranolol attenuates cognitive, learning, and memory deficits in a murine model of traumatic brain injury. J Trauma Acute Care Surg 2020; 87:1140-1147. [PMID: 31425494 DOI: 10.1097/ta.0000000000002484] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND β-blockers have been shown to improve survival after traumatic brain injury (TBI); however, the impact of continuous dosage of β-blockers on cognitive function has not been elucidated. We hypothesized that a daily dose of propranolol can improve memory, learning, and cognitive function following TBI. STUDY DESIGN Twenty male C57BL mice were subjected to a cortical-controlled moderate TBI. Two hours after TBI, animals were randomly allocated to either the β-blocker group (n = 10) or the placebo group (n = 10). Mice in the β-blocker group received intraperitoneal 4 mg/kg propranolol every 24 hours for 7 days while the placebo group received 4 mg/kg normal saline. Baseline novel object recognition and classic maze tests were done prior to TBI and then daily from Day 1 through 7 after TBI. Animals were sacrificed on Day 7. Serum biomarkers were measured using ELISA and brain sections were analyzed using western blot and hematoxylin and eosin staining. RESULTS Both the β-blocker and placebo groups had lower recognition index scores compared with the baseline following TBI. β-blocker mice had significantly higher novel object recognition scores compared with placebo mice 2 days after TBI. The β-blocker group required less time to complete the maze-test compared to placebo group after Day 4. There was no difference regarding the serum levels of IL-1β, IL-6, and TNF-α. The β-blocker group had lower levels of UCHL-1 and higher levels of Hsp-70 in brain lysate. Hematoxylin and eosin staining revealed that more neurons in the hippocampal-CA1 area underwent apoptosis in the placebo group compared with the β-blocker group. CONCLUSION Postinjury propranolol administration results in improved memory, learning and cognitive functions in a murine model of moderate TBI. Propranolol increases the expression of antiapoptotic protein (Hsp-70) and decreases cell death in the hippocampal-CA1 area compared with the placebo.
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14
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Wu Y, Cui J. (-)-Epigallocatechin-3-gallate provides neuroprotection via AMPK activation against traumatic brain injury in a mouse model. Naunyn Schmiedebergs Arch Pharmacol 2020; 393:2209-2220. [PMID: 32062732 DOI: 10.1007/s00210-020-01841-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 02/06/2020] [Indexed: 12/11/2022]
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. (-)-Epigallocatechin-3-gallate (EGCG) has shown robust neuroprotective effects on various brain injury models in rodents. Herein, we aimed to investigate if EGCG protects against TBI and unravel the underlying mechanisms. A total of 102 mice were used for this study. TBI was induced by controlled cortical impact (CCI). EGCG was given immediately after TBI injury. Neurological functions were accessed by corner test, paw placement, modified neurological severity score, rotarod test, and Morris water maze test. AMPK inhibitor and AMPKα1-knockout mice were used to further study the signaling pathways involved in the observed effects. Our results show that EGCG significantly ameliorated CCI-induced neurological impairment, including spatial learning and memory. EGCG suppressed CCI-induced inflammation and oxidative stress. Furthermore, EGCG downregulated the phosphorylation of IKKα/β, IκBα, and nuclear translocation of NF-κB p65; upregulated AMPK phosphorylation; and altered corresponding changes in the phosphorylation of the downstream target's ribosomal protein S6, AS160, and CaMKKß. Our data demonstrate that EGCG protects against CCI-induced TBI through the activation of the AMPK pathway in mice, suggesting that EGCG might be a promising therapeutic intervention preventing locomotor and cognitive impairments after TBI.
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Affiliation(s)
- Yinyin Wu
- The Second People's Hospital of Hefei City, Intersection of Guangde Road and Leshui Road, Yaohai District, Hefei, 230011, Anhui, China.
| | - Jing Cui
- The Second People's Hospital of Hefei City, Intersection of Guangde Road and Leshui Road, Yaohai District, Hefei, 230011, Anhui, China
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15
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Beta-Blocker Therapy in Severe Traumatic Brain Injury: A Prospective Randomized Controlled Trial. World J Surg 2020; 44:1844-1853. [DOI: 10.1007/s00268-020-05391-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Abstract
Background
Observational studies have demonstrated improved outcomes in TBI patients receiving in-hospital beta-blockers. The aim of this study is to conduct a randomized controlled trial examining the effect of beta-blockers on outcomes in TBI patients.
Methods
Adult patients with severe TBI (intracranial AIS ≥ 3) were included in the study. Hemodynamically stable patients at 24 h after injury were randomized to receive either 20 mg propranolol orally every 12 h up to 10 days or until discharge (BB+) or no propranolol (BB−). Outcomes of interest were in-hospital mortality and Glasgow Outcome Scale-Extended (GOS-E) score on discharge and at 6-month follow-up. Subgroup analysis including only isolated severe TBI (intracranial AIS ≥ 3 with extracranial AIS ≤ 2) was carried out. Poisson regression models were used.
Results
Two hundred nineteen randomized patients of whom 45% received BB were analyzed. There were no significant demographic or clinical differences between BB+ and BB− cohorts. No significant difference in in-hospital mortality (adj. IRR 0.6 [95% CI 0.3–1.4], p = 0.2) or long-term functional outcome was measured between the cohorts (p = 0.3). One hundred fifty-four patients suffered isolated severe TBI of whom 44% received BB. The BB+ group had significantly lower mortality relative to the BB− group (18.6% vs. 4.4%, p = 0.012). On regression analysis, propranolol had a significant protective effect on in-hospital mortality (adj. IRR 0.32, p = 0.04) and functional outcome at 6-month follow-up (GOS-E ≥ 5 adj. IRR 1.2, p = 0.02).
Conclusion
Propranolol decreases in-hospital mortality and improves long-term functional outcome in isolated severe TBI. This randomized trial speaks in favor of routine administration of beta-blocker therapy as part of a standardized neurointensive care protocol.
Level of evidence
Level II; therapeutic.
Study type
Therapeutic study.
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16
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Lemmens S, Nelissen S, Dooley D, Geurts N, Peters EMJ, Hendrix S. Stress Pathway Modulation Is Detrimental or Ineffective for Functional Recovery after Spinal Cord Injury in Mice. J Neurotrauma 2019; 37:564-571. [PMID: 31210094 DOI: 10.1089/neu.2018.6211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
A mounting body of evidence suggests that stress plays a major role in the injury progression after spinal cord injury (SCI). Injury activates the stress systems; this in turn may augment the generation of pro-inflammatory cytokines, stimulate pro-inflammatory immune cells, and alter the balance between the pro- and anti-inflammatory immune response. As a result, it is suggested that stress pathways may augment neuronal damage and loss after SCI. Considering these potential detrimental effects of stress after SCI, we hypothesized that inhibition of stress pathways immediately after SCI may offer protection from damage and improve recovery. To investigate the relevance of stress responses in SCI recovery, we investigated the effects of blocking three well-studied stress response axes in a mouse model of SCI. Propranolol, RU-486, and CP-99994 were administered to inhibit the sympathetic axis, the hypothalamus-pituitary-adrenal axis, and the neuropeptide axis, respectively. Surprisingly, assessing functional recovery by the Basso Mouse Scale revealed that RU-486 and CP-99994 did not affect functional outcome, indicating that these pathways are dispensable for neuroprotection or repair after SCI. Moreover, the beta-blocker propranolol worsened functional outcome in the mouse SCI model. In conclusion, immediate inhibition of three major stress axes has no beneficial effects on functional recovery after SCI in mice. These results suggest that injury-induced stress responses do not interfere with the healing process and hence, pharmacological targeting of stress responses is not a recommended treatment option for SCI. These findings are of great importance for other researchers to avoid unnecessary and potentially futile animal experiments.
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Affiliation(s)
- Stefanie Lemmens
- Department of Morphology, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Sofie Nelissen
- Department of Morphology, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Dearbhaile Dooley
- Health Science Centre, School of Medicine, University College Dublin, Belfield, Dublin, Ireland
| | - Nathalie Geurts
- Department of Morphology, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Eva Milena Johanne Peters
- Psychoneuroimmunology Laboratory, Department of Psychosomatic Medicine, Justus Liebig University and Charité Berlin, Germany
| | - Sven Hendrix
- Department of Morphology, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
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17
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Abstract
PURPOSE OF REVIEW Traumatic brain injury (TBI) is a leading cause of morbidity and mortality; however, little definitive evidence exists about most clinical management strategies. Here, we highlight important differences between two major guidelines, the 2016 Brain Trauma Foundation guidelines and the Lund Concept, along with recent pre-clinical and clinical data. RECENT FINDINGS While intracranial pressure (ICP) monitoring has been questioned, the majority of literature demonstrates benefit in severe TBI. The optimal cerebral perfusion pressure (CPP) and ICP are yet unknown, but likely as important is the concept of ICP burden. The evidence for anti-hypertensive therapy is strengthening. Decompressive craniectomy improves mortality, but at the cost of increased morbidity. Plasma-based resuscitation has demonstrated benefit in multiple pre-clinical TBI studies. SUMMARY The management of hemodynamics and intravascular volume are crucial in TBI. Based on recent evidence, ICP monitoring, anti-hypertensive therapy, minimal use of vasopressors/inotropes, and plasma resuscitation may improve outcomes.
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Affiliation(s)
- Henry W. Caplan
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
| | - Charles S. Cox
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX
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18
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Barnard DF, Gabella KM, Kulp AC, Parker AD, Dugan PB, Johnson JD. Sex differences in the regulation of brain IL-1β in response to chronic stress. Psychoneuroendocrinology 2019; 103:203-211. [PMID: 30711897 PMCID: PMC6526725 DOI: 10.1016/j.psyneuen.2019.01.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 01/08/2023]
Abstract
Elevations in brain interleukin-1 beta (IL-1β) during chronic stress exposure have been implicated in behavioral and cognitive impairments associated with depression and anxiety. Two critical regulators of brain IL-1β production during times of stress are glucocorticoids and catecholamines. These hormones work in opposition to one another to inhibit (via glucocorticoid receptors) or stimulate (via beta-adrenergic receptors: β-AR) IL-1β production. While chronic stress often heightens both corticosterone and catecholamine levels, it remains unknown as to how chronic stress may affect the "yin-yang" balance between adrenergic stimulation and glucocorticoid suppression of brain IL-1β. To investigate this further, male and female rats underwent 4 days of stress exposure or served as non-stressed controls. On day 5, animals were administered propranolol (β-AR antagonist), metyrapone (a glucocorticoid synthesis inhibitor), vehicle, or both drugs and brain IL-1β mRNA was measured by rtPCR in limbic brain areas. In males, administration of propranolol had no effect on IL-1β expression in non-stressed controls but significantly reduced IL-1β in the hippocampus and amygdala of chronically stressed animals. In females, propranolol significantly reduced IL-1β in the amygdala and hypothalamus of both control and stressed rats. In male rats, metyrapone treatment significantly increased IL-1β mRNA regardless of stress treatment in all brain areas, while in female rats metyrapone only increased IL-1β in the hypothalamus. Interestingly, propranolol treatment blocked the metyrapone-induced increase in brain IL-1β indicating the increase in brain IL-1β following metyrapone treatment was due to increase β-AR activation. Additional studies revealed that metyrapone significantly increases norepinephrine turnover in the hypothalamus and medial prefrontal cortex in male rats and that microglia appear to be the cell type contributing to the production of IL-1β. Overall, data reveal that stress exposure in male rats affects the regulation of brain IL-1β by the norepinephrine-β-AR pathway, while stress had no effect in the regulation of brain IL-1β in female rats.
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Affiliation(s)
- David F. Barnard
- Kent State University, Biological Sciences Department, Kent, Ohio 44240, United States
| | - Kristin M. Gabella
- Kent State University, Biological Sciences Department, Kent, Ohio 44240, United States
| | - Adam C. Kulp
- Kent State University, Biological Sciences Department, Kent, Ohio 44240, United States,Kent State University, School of Biomedical Sciences, Kent, Ohio 44240, United States
| | - Austin D. Parker
- Kent State University, Biological Sciences Department, Kent, Ohio 44240, United States
| | - Patrick B. Dugan
- Kent State University, Biological Sciences Department, Kent, Ohio 44240, United States
| | - John D. Johnson
- Kent State University, Biological Sciences Department, Kent, Ohio 44240, United States,Kent State University, School of Biomedical Sciences, Kent, Ohio 44240, United States
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19
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Beta blockers in critically ill patients with traumatic brain injury: Results from a multicenter, prospective, observational American Association for the Surgery of Trauma study. J Trauma Acute Care Surg 2019; 84:234-244. [PMID: 29251711 DOI: 10.1097/ta.0000000000001747] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Beta blockers, a class of medications that inhibit endogenous catecholamines interaction with beta adrenergic receptors, are often administered to patients hospitalized after traumatic brain injury (TBI). We tested the hypothesis that beta blocker use after TBI is associated with lower mortality, and secondarily compared propranolol to other beta blockers. METHODS The American Association for the Surgery of Trauma Clinical Trial Group conducted a multi-institutional, prospective, observational trial in which adult TBI patients who required intensive care unit admission were compared based on beta blocker administration. RESULTS From January 2015 to January 2017, 2,252 patients were analyzed from 15 trauma centers in the United States and Canada with 49.7% receiving beta blockers. Most patients (56.3%) received the first beta blocker dose by hospital day 1. Those patients who received beta blockers were older (56.7 years vs. 48.6 years, p < 0.001) and had higher head Abbreviated Injury Scale scores (3.6 vs. 3.4, p < 0.001). Similarities were noted when comparing sex, admission hypotension, mean Injury Severity Score, and mean Glasgow Coma Scale. Unadjusted mortality was lower for patients receiving beta blockers (13.8% vs. 17.7%, p = 0.013). Multivariable regression determined that beta blockers were associated with lower mortality (adjusted odds ratio, 0.35; p < 0.001), and propranolol was superior to other beta blockers (adjusted odds ratio, 0.51, p = 0.010). A Cox-regression model using a time-dependent variable demonstrated a survival benefit for patients receiving beta blockers (adjusted hazard ratio, 0.42, p < 0.001) and propranolol was superior to other beta blockers (adjusted hazard ratio, 0.50, p = 0.003). CONCLUSION Administration of beta blockers after TBI was associated with improved survival, before and after adjusting for the more severe injuries observed in the treatment cohort. This study provides a robust evaluation of the effects of beta blockers on TBI outcomes that supports the initiation of a multi-institutional randomized control trial. LEVEL OF EVIDENCE Therapeutic/care management, level III.
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20
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21
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22
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Wagner AK, Kumar RG. TBI Rehabilomics Research: Conceptualizing a humoral triad for designing effective rehabilitation interventions. Neuropharmacology 2018; 145:133-144. [PMID: 30222984 DOI: 10.1016/j.neuropharm.2018.09.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/14/2018] [Accepted: 09/10/2018] [Indexed: 12/11/2022]
Abstract
Most areas of medicine use biomarkers in some capacity to aid in understanding how personal biology informs clinical care. This article draws upon the Rehabilomics research model as a translational framework for programs of precision rehabilitation and intervention research focused on linking personal biology to treatment response using biopsychosocial constructs that broadly represent function and that can be applied to many clinical populations with disability. The summary applies the Rehabilomics research framework to the population with traumatic brain injury (TBI) and emphasizes a broad vision for biomarker inclusion, beyond typical brain-derived biomarkers, to capture and/or reflect important neurological and non-neurological pathology associated with TBI as a chronic condition. Humoral signaling molecules are explored as important signaling and regulatory drivers of these chronic conditions and their impact on function. Importantly, secondary injury cascades involved in the humoral triad are influenced by the systemic response to TBI and the development of non-neurological organ dysfunction (NNOD). Biomarkers have been successfully leveraged in other medical fields to inform pre-randomization patient selection for clinical trials, however, this practice largely has not been utilized in TBI research. As such, the applicability of the Rehabilomics research model to contemporary clinical trials and comparative effectiveness research designs for neurological and rehabilitation populations is emphasized. Potential points of intervention to modify inflammation, hormonal, or neurotrophic support through rehabilitation interventions are discussed. This article is part of the Special Issue entitled "Novel Treatments for Traumatic Brain Injury".
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Affiliation(s)
- A K Wagner
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, USA; Safar Center for Resuscitation Research, University of Pittsburgh, USA; Department of Neuroscience, University of Pittsburgh, USA; Center for Neuroscience, University of Pittsburgh, USA.
| | - R G Kumar
- Department of Physical Medicine & Rehabilitation, University of Pittsburgh, USA; Safar Center for Resuscitation Research, University of Pittsburgh, USA; Department of Epidemiology, University of Pittsburgh, USA
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23
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Ranganathan P, Kumar RG, Oh BM, Rakholia MV, Berga SL, Wagner AK. Estradiol to Androstenedione Ratios Moderate the Relationship between Neurological Injury Severity and Mortality Risk after Severe Traumatic Brain Injury. J Neurotrauma 2018; 36:538-547. [PMID: 30014751 DOI: 10.1089/neu.2018.5677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Early declines in gonadotropin production, despite elevated serum estradiol, among some individuals with severe traumatic brain injury (TBI) suggests amplified systemic aromatization occurs post-injury. Our previous work identifies estradiol (E2) as a potent mortality marker. Androstenedione (A), a metabolic precursor to E2, estrone (E1), and testosterone (T), is a steroid hormone substrate for aromatization that has not been explored previously as a biomarker in TBI. Here, we evaluated serum A, E1, T, and E2 values for 82 subjects with severe TBI. Daily hormone values were calculated, and E2:A and E1:T ratios were generated and then averaged for days 0-3 post-injury. After data inspection, mean E2:A values were categorized as above (high aromatization) and below (low aromatization) the 50th percentile for 30-day mortality assessment using Kaplan-Meier survival analysis and a multivariable Cox proportional hazard model adjusting for age, and Glasgow Coma Scale (GCS) to predict 30-day mortality status. Daily serum T, E1, and E2 were graphed by E2:A category. Serum E1 and E2 significantly differed over time (p < 0.05); the high aromatization group had elevated levels and a significantly lower probability of survival within the first 30 days (p = 0.0274). Multivariable Cox regression showed a significant E2:A*GCS interaction (p = 0.0129), wherein GCS predicted mortality only among those in the low aromatization group. E2:A may be a useful mortality biomarker representing enhanced aromatization after TBI. E2:A ratios may represent non-neurological organ dysfunction after TBI and may be useful in defining injury subgroups in which GCS has variable capacity to serve as an accurate early prognostic marker.
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Affiliation(s)
- Prerna Ranganathan
- 1 Department of Physical Medicine and Rehabilitation, University of Pittsburgh , Pittsburgh, Pennslvania
| | - Raj G Kumar
- 1 Department of Physical Medicine and Rehabilitation, University of Pittsburgh , Pittsburgh, Pennslvania
| | - Byung-Mo Oh
- 2 Department of Rehabilitation Medicine, Seoul National University Hospital , Seoul, Korea
| | - Milap V Rakholia
- 1 Department of Physical Medicine and Rehabilitation, University of Pittsburgh , Pittsburgh, Pennslvania
| | - Sarah L Berga
- 3 Department of Obstetrics and Gynecology, University of Utah Medical Center , Salt Lake City, Utah
| | - Amy K Wagner
- 1 Department of Physical Medicine and Rehabilitation, University of Pittsburgh , Pittsburgh, Pennslvania.,4 Department of Neuroscience, University of Pittsburgh , Pittsburgh, Pennsylvania.,5 Center for Neuroscience, University of Pittsburgh , Pittsburgh, Pennsylvania.,6 Clinical and Translational Science Institute, University of Pittsburgh , Pittsburgh, Pennsylvania
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24
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Rakholia MV, Kumar RG, Oh BM, Ranganathan PR, Berga SL, Kochanek PM, Wagner AK. Systemic Estrone Production and Injury-Induced Sex Hormone Steroidogenesis after Severe Traumatic Brain Injury: A Prognostic Indicator of Traumatic Brain Injury-Related Mortality. J Neurotrauma 2018; 36:1156-1167. [PMID: 29947289 DOI: 10.1089/neu.2018.5782] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Extensive pre-clinical studies suggest that sex steroids are neuroprotective in experimental traumatic brain injury (TBI). However, clinical trials involving sex hormone administration have not shown beneficial results, and our observational cohort studies show systemic estradiol (E2) production to be associated with adverse outcomes. Systemic E2 is produced via aromatization of testosterone (T) or reduction of estrone (E1). E1, also produced via aromatization of androstenedione (Andro) and is a marker of T-independent E2 production. We hypothesized that E1 would be (1) associated with TBI-related mortality, (2) the primary intermediate for E2 production, and (3) associated with adipose tissue-specific aromatase transcription. We assessed 100 subjects with severe TBI and 8 healthy controls. Serum levels were measured on days 0-3 post-TBI for key steroidogenic precursors (progesterone), aromatase pathway intermediates (E1, E2, T, Andro), and the adipose tissue-specific aromatase transcription factors cortisol, tumor necrosis factor-alpha (TNF-α), and interleukin-6 (IL-6). E1 was elevated after TBI versus controls. High E1 was associated with higher progesterone, cortisol, and IL-6 (p < 0.05). Multivariable logistic regression demonstrated that those in the highest E1 tertile had increased odds for mortality (adjusted OR = 5.656, 95% CI = 1.102-29.045, p = 0.038). Structural equation models show that early serum E2 production is largely T independent, occurring predominantly through E1 metabolism. Acute serum E1 functions as a mortality marker for TBI through aromatase-dependent E1 production and T-independent E2 production. Further work should evaluate risk factors for high E2 production and how systemic E2 and its key intermediate E1 contribute to the extracerebral consequences of severe TBI.
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Affiliation(s)
- Milap V Rakholia
- 1 Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh Pennsylvania
| | - Raj G Kumar
- 1 Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh Pennsylvania
| | - Byung-Mo Oh
- 2 Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Prerna R Ranganathan
- 1 Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh Pennsylvania
| | - Sarah L Berga
- 3 Department of Obstetrics and Gynecology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Patrick M Kochanek
- 4 Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh Pennsylvania.,5 Department of Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh Pennsylvania
| | - Amy K Wagner
- 1 Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh Pennsylvania.,5 Department of Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh Pennsylvania.,6 Department of Neuroscience, University of Pittsburgh, Pittsburgh Pennsylvania.,7 Department of Center for Neuroscience, University of Pittsburgh, Pittsburgh Pennsylvania
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Effects of propranolol and clonidine on brain edema, blood-brain barrier permeability, and endothelial glycocalyx disruption after fluid percussion brain injury in the rat. J Trauma Acute Care Surg 2018; 84:89-96. [PMID: 28930945 DOI: 10.1097/ta.0000000000001708] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traumatic brain injury causes a disruption of the vascular endothelial glycocalyx layer that is associated with an overactivation of the sympathoadrenal system. We hypothesized that early and unselective beta-blockade with propranolol alone or in combination with the alfa2-agonist clonidine would decrease brain edema, blood-brain barrier permeability, and glycocalyx disruption at 24 hours after trauma. METHODS We subjected 53 adult male Sprague-Dawley rats to lateral fluid percussion brain injury and randomized infusion with propranolol (n = 16), propranolol + clonidine (n = 16), vehicle (n = 16), or sham (n = 5) for 24 hours. Primary outcome was brain water content at 24 hours. Secondary outcomes were blood-brain barrier permeability and plasma levels of syndecan-1 (glycocalyx disruption), cell damage (histone-complexed DNA fragments), epinephrine, norepinephrine, and animal motor function. RESULTS We found no difference in brain water content (mean ± SD) between propranolol (80.8 ± 0.3%; 95% confidence interval [CI], 80.7-81.0) and vehicle (81.1 ± 0.6%; 95% CI, 80.8-81.4) (p = 0.668) or between propranolol/clonidine (80.8 ± 0.3%; 95% CI, 80.7-81.0) and vehicle (p = 0.555). We found no effect of propranolol and propranolol/clonidine on blood-brain barrier permeability and animal motor scores. Unexpectedly, propranolol and propranolol/clonidine caused an increase in epinephrine and syndecan-1 levels. CONCLUSION This study does not provide any support for unselective beta-blockade with propranolol or the combination of propranolol and the alfa2-agonist clonidine on brain water content. The novel finding of an increase in plasma concentrations of epinephrine and syndecan-1 after propranolol treatment in traumatic brain injury is of unclear significance and should be investigated further.
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Liou DZ, Ko A, Volod O, Barmparas G, Harada MY, Martin MJ, Salim A, Dhillon N, Thomsen GM, Ley EJ. Thromboelastography After Murine TBI and Implications of Beta-Adrenergic Receptor Knockout. Neurocrit Care 2017; 25:145-52. [PMID: 26666545 DOI: 10.1007/s12028-015-0223-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The source of coagulopathy in traumatic brain injury (TBI) is multifactorial and may include adrenergic stimulation. The aim of this study was to assess coagulopathy after TBI using thromboelastography (TEG), and to investigate the implications of β-adrenergic receptor knockout. METHODS Adult male wild type c57/bl6 (WT) and β1/β2-adrenergic receptor knockout (BKO) mice were assigned to either TBI (WT-TBI, BKO-TBI) or sham injury (WT-sham, BKO-sham). Mice assigned to TBI were subject to controlled cortical impact (CCI). At 24 h post-injury, whole blood samples were obtained and taken immediately for TEG. RESULTS At 24 h after injury, a trend toward increased fibrinolysis was seen in WT-TBI compared to WT-sham although this did not reach significance (EPL 8.1 vs. 0 %, p = 0.18). No differences were noted in fibrinolysis in BKO-TBI compared to BKO-sham (LY30 2.6 vs. 2.5 %, p = 0.61; EPL 3.4 vs. 2.9 %, p = 0.61). In addition BKO-TBI demonstrated increased clot strength compared to BKO-sham (MA 76.6 vs. 68.6, p = 0.03; G 18.2 vs. 11.3, p = 0.03). CONCLUSIONS In a mouse TBI model, WT mice sustaining TBI demonstrated a trend toward increased fibrinolysis at 24 h after injury while BKO mice did not. These findings suggest β-blockade may attenuate the coagulopathy of TBI and minimize progression of intracranial hemorrhage by reducing fibrinolysis and increasing clot strength.
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Affiliation(s)
- Douglas Z Liou
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA, 90048, USA
| | - Ara Ko
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA, 90048, USA
| | - Oksana Volod
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Galinos Barmparas
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA, 90048, USA
| | - Megan Y Harada
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA, 90048, USA
| | - Matthew J Martin
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA, USA
| | - Ali Salim
- Department of Surgery, Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Navpreet Dhillon
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA, 90048, USA
| | - Gretchen M Thomsen
- Board of Governors Regenerative Medicine Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric J Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA, 90048, USA.
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Chen Z, Tang L, Xu X, Wei X, Wen L, Xie Q. Therapeutic effect of beta-blocker in patients with traumatic brain injury: A systematic review and meta-analysis. J Crit Care 2017; 41:240-246. [PMID: 28595083 DOI: 10.1016/j.jcrc.2017.05.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2017] [Revised: 05/03/2017] [Accepted: 05/28/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE β-Blocker exposure has been shown to reduce mortality in traumatic brain injury (TBI); however, the efficacy of β-blockers remains inconclusive. Therefore, a meta-analysis was conducted in this paper to evaluate the safety and efficacy of β-blocker therapy on patients with TBI. METHODS The electronic databases were systemically retrieved from construction to February 2017. The odds ratio (OR), mean difference (MD) and 95% confidence intervals (CI) were determined. RESULTS A total of 13 observational cohort studies involving 15,734 cases were enrolled. The results indicated that β-blocker therapy had remarkably reduced the in-hospital mortality (OR 0.33; 95% CI 0.27-0.40; p<0.001). However, β-blocker therapy was also associated with increased infection rate (OR 2.01; 95% CI 1.50-2.69; p<0.001), longer length of stay (MD=7.40; 95% CI=4.39, 10.41; p<0.001) and ICU stay (MD=3.52; 95% CI=1.56, 5.47; p<0.001). In addition, β-blocker therapy also led to longer period of ventilator support (MD=2.70; 95% CI=1.81, 3.59; p<0.001). CONCLUSION The meta-analysis demonstrates that β-blockers are effective in lowering mortality in patients with TBI. However, β-blocker therapy has markedly increased the infection rate and requires a longer period of ventilator support, intensive care management as well as length of stay.
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Affiliation(s)
- Zaifeng Chen
- Department of Neurosurgery, Wenzhou Medical University Affiliated Cixi Hospital, Cixi, Zhejiang, PR China
| | - Linjun Tang
- Department of Neurosurgery, Tongling Municipal Hospital, Tongling, Anhui, PR China
| | - Xinlong Xu
- Department of Neurosurgery, Wenzhou Medical University Affiliated Cixi Hospital, Cixi, Zhejiang, PR China
| | - Xiaojie Wei
- Department of Neurosurgery, Wenzhou Medical University Affiliated Cixi Hospital, Cixi, Zhejiang, PR China
| | - Lutong Wen
- Department of Neurosurgery, Wenzhou Medical University Affiliated Cixi Hospital, Cixi, Zhejiang, PR China
| | - Qingsong Xie
- Department of Neurosurgery, Wenzhou Medical University Affiliated Cixi Hospital, Cixi, Zhejiang, PR China.
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Wang H, Zhang YP, Cai J, Shields LBE, Tuchek CA, Shi R, Li J, Shields CB, Xu XM. A Compact Blast-Induced Traumatic Brain Injury Model in Mice. J Neuropathol Exp Neurol 2016; 75:183-96. [PMID: 26802177 DOI: 10.1093/jnen/nlv019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Blast-induced traumatic brain injury (bTBI) is a common injury on the battlefield and often results in permanent cognitive and neurological abnormalities. We report a novel compact device that creates graded bTBI in mice. The injury severity can be controlled by precise pressures that mimic Friedlander shockwave curves. The mouse head was stabilized with a head fixator, and the body was protected with a metal shield; shockwave durations were 3 to 4 milliseconds. Reflective shockwave peak readings at the position of the mouse head were 12 6 2.6 psi, 50 6 20.3 psi, and 100 6 33.1 psi at 100, 200, and 250 psi predetermined driver chamber pressures, respectively. The bTBIs of 250 psi caused 80% mortality, which decreased to 27% with the metal shield. Brain and lung damage depended on the shockwave duration and amplitude. Cognitive deficits were assessed using the Morris water maze, Y-maze, and open-field tests. Pathological changes in the brain included disruption of the blood-brain barrier, multifocal neuronal and axonal degeneration, and reactive gliosis assessed by Evans Blue dye extravasation, silver and Fluoro-Jade B staining, and glial fibrillary acidic protein immunohistochemistry, respectively. Behavioral and pathological changes were injury severity-dependent. This mouse bTBI model may be useful for investigating injury mechanisms and therapeutic strategies associated with bTBI.
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29
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Di Battista AP, Rhind SG, Hutchison MG, Hassan S, Shiu MY, Inaba K, Topolovec-Vranic J, Neto AC, Rizoli SB, Baker AJ. Inflammatory cytokine and chemokine profiles are associated with patient outcome and the hyperadrenergic state following acute brain injury. J Neuroinflammation 2016; 13:40. [PMID: 26883121 PMCID: PMC4754875 DOI: 10.1186/s12974-016-0500-3] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 02/01/2016] [Indexed: 01/25/2023] Open
Abstract
Background Traumatic brain injury (TBI) elicits intense sympathetic nervous system (SNS) activation with profuse catecholamine secretion. The resultant hyperadrenergic state is linked to immunomodulation both within the brain and systemically. Dysregulated inflammation post-TBI exacerbates secondary brain injury and contributes to unfavorable patient outcomes including death. The aim of this study was to characterize the early dynamic profile of circulating inflammatory cytokines/chemokines in patients admitted for moderate-to-severe TBI, to examine interrelationships between these mediators and catecholamines, as well as clinical indices of injury severity and neurological outcome. Methods Blood was sampled from 166 isolated TBI patients (aged 45 ± 20.3 years; 74.7 % male) on admission, 6-, 12-, and 24-h post-injury and from healthy controls (N = 21). Plasma cytokine [interleukin (IL)-1β, -2, -4, -5, -10, -12p70, -13, tumor necrosis factor (TNF)-α, interferon (IFN)-γ] and chemokine [IL-8, eotaxin, eotaxin-3, IFN-γ-induced protein (IP)-10, monocyte chemoattractant protein (MCP)-1, -4, macrophage-derived chemokine (MDC), macrophage inflammatory protein (MIP)-1β, thymus activation regulated chemokine (TARC)] concentrations were analyzed using high-sensitivity electrochemiluminescence multiplex immunoassays. Plasma catecholamines [epinephrine (Epi), norepinephrine (NE)] were measured by immunoassay. Neurological outcome at 6 months was assessed using the extended Glasgow outcome scale (GOSE) dichotomized as good (>4) or poor (≤4) outcomes. Results Patients showed altered levels of IL-10 and all chemokines assayed relative to controls. Significant differences in a number of markers were evident between moderate and severe TBI cohorts. Elevated IL-8, IL-10, and TNF-α, as well as alterations in 8 of 9 chemokines, were associated with poor outcome at 6 months. Notably, a positive association was found between Epi and IL-1β, IL-10, Eotaxin, IL-8, and MCP-1. NE was positively associated with IL-1β, IL-10, TNF-α, eotaxin, IL-8, IP-10, and MCP-1. Conclusions Our results provide further evidence that exaggerated SNS activation acutely after isolated TBI in humans may contribute to harmful peripheral inflammatory cytokine/chemokine dysregulation. These findings are consistent with a potentially beneficial role for therapies aimed at modulating the inflammatory response and hyperadrenergic state acutely post-injury. Electronic supplementary material The online version of this article (doi:10.1186/s12974-016-0500-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alex P Di Battista
- Defence Research & Development Canada, Toronto Research Centre, Toronto, ON, Canada. .,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
| | - Shawn G Rhind
- Defence Research & Development Canada, Toronto Research Centre, Toronto, ON, Canada. .,Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada.
| | - Michael G Hutchison
- Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada. .,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hopsital, Toronto, ON, Canada.
| | - Syed Hassan
- Defence Research & Development Canada, Toronto Research Centre, Toronto, ON, Canada. .,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
| | - Maria Y Shiu
- Defence Research & Development Canada, Toronto Research Centre, Toronto, ON, Canada. .,Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada.
| | - Kenji Inaba
- Division of Trauma & Critical Care, University of Southern California, Los Angeles, CA, USA. .,LA County+ USC Medical Center, Los Angeles, CA, USA.
| | - Jane Topolovec-Vranic
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hopsital, Toronto, ON, Canada.
| | | | - Sandro B Rizoli
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hopsital, Toronto, ON, Canada. .,Department of Critical Care, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada. .,Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada. .,Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
| | - Andrew J Baker
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada. .,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hopsital, Toronto, ON, Canada. .,Department of Critical Care, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada. .,Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada. .,Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
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Kota DJ, Prabhakara KS, van Brummen AJ, Bedi S, Xue H, DiCarlo B, Cox CS, Olson SD. Propranolol and Mesenchymal Stromal Cells Combine to Treat Traumatic Brain Injury. Stem Cells Transl Med 2015; 5:33-44. [PMID: 26586775 DOI: 10.5966/sctm.2015-0065] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 09/14/2015] [Indexed: 01/22/2023] Open
Abstract
UNLABELLED More than 6.5 million patients are burdened by the physical, cognitive, and psychosocial deficits associated with traumatic brain injury (TBI) in the U.S. Despite extensive efforts to develop neuroprotective therapies for this devastating disorder, there have been no successful outcomes in human clinical trials to date. Retrospective studies have shown that β-adrenergic receptor blockers, specifically propranolol, significantly decrease mortality of TBI through mechanisms not yet fully elucidated but are thought to counterbalance a hyperadrenergic state resulting from a TBI. Conversely, cellular therapies have been shown to improve long-term behavior following TBI, likely by reducing inflammation. Given the nonredundancy in their therapeutic mechanisms, we hypothesized that a combination of acute propranolol followed by mesenchymal stem cells (MSCs) isolated from human bone marrow would have additive effects in treating a rodent model of TBI. We have found that the treatments are well-tolerated individually and in combination with no adverse events. MSCs decrease BBB permeability at 96 hours after injury, inhibit a significant accumulation of activated microglia/macrophage in the thalamic region of the brain both short and long term, and enhance neurogenesis short term. Propranolol decreases edema and reduces the number of fully activated microglia at 7 days and the number of semiactivated microglia at 120 days. Combinatory treatment improved cognitive and memory functions 120 days following TBI. Therefore, the results here suggest a new, efficacious sequential treatment for TBI may be achieved using the β-blocker propranolol followed by MSC treatment. SIGNIFICANCE Despite continuous efforts, traumatic brain injury (TBI) remains the leading cause of death and disability worldwide in patients under the age of 44. In this study, an animal model of moderate-severe TBI was treated with an acute dose of propranolol followed by a delayed dose of human mesenchymal stem cells (MSCs), resulting in improved short- and long-term measurements. These results have direct translational application. They reinforce the inevitable clinical trial of MSCs to treat TBI by demonstrating, among other benefits, a notable decrease in chronic neuroinflammation. More importantly, these results demonstrate that MSCs and propranolol, which is increasingly being used clinically for TBI, are compatible treatments that improve overall outcome.
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Affiliation(s)
- Daniel J Kota
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Karthik S Prabhakara
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Alexandra J van Brummen
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Supinder Bedi
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Hasen Xue
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Bryan DiCarlo
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles S Cox
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Scott D Olson
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
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Zangbar B, Khalil M, Rhee P, Joseph B, Kulvatunyou N, Tang A, Friese RS, O'Keeffe T. Metoprolol improves survival in severe traumatic brain injury independent of heart rate control. J Surg Res 2015; 200:586-92. [PMID: 26365164 DOI: 10.1016/j.jss.2015.08.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 07/16/2015] [Accepted: 08/14/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Multiple prior studies have suggested an association between survival and beta-blocker administration in patients with severe traumatic brain injury (TBI). However, it is unknown whether this benefit of beta-blockers is dependent on heart rate control. The aim of this study was to assess whether rate control affects survival in patients receiving metoprolol with severe TBI. Our hypothesis was that improved survival from beta-blockade would be associated with a reduction in heart rate. METHODS We performed a 7-y retrospective analysis of all blunt TBI patients at a level-1 trauma center. Patients aged >16 y with head abbreviated injury scale 4 or 5, admitted to the intensive care unit (ICU) from the operating room or emergency room (ER), were included. Patients were stratified into two groups: metoprolol and no beta-blockers. Using propensity score matching, we matched the patients in two groups in a 1:1 ratio controlling for age, gender, race, admission vital signs, Glasgow coma scale, injury severity score, mean heart rate monitored during ICU admission, and standard deviation of heart rate during the ICU admission. Our primary outcome measure was mortality. RESULTS A total of 914 patients met our inclusion criteria, of whom 189 received beta-blockers. A propensity-matched cohort of 356 patients (178: metoprolol and 178: no beta-blockers) was created. Patients receiving metoprolol had higher survival than those patients who did not receive beta-blockers (78% versus 68%; P = 0.04); however, there was no difference in the mean heart rate (89.9 ± 13.9 versus 89.9 ± 15; P = 0.99). Nor was there a difference in the mean of standard deviation of the heart rates (14.7 ± 6.3 versus 14.4 ± 6.5; P = 0.65) between the two groups. In Kaplan-Meier survival analysis, patients who received metoprolol had a survival advantage (P = 0.011) compared with patients who did not receive any beta-blockers. CONCLUSIONS Our study shows an association with improved survival in patients with severe TBI receiving metoprolol, and this effect appears to be independent of any reduction in heart rate. We suggest that beta-blockers should be administered to all severe TBI patients irregardless of any perceived beta-blockade effect on heart rate.
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Affiliation(s)
- Bardiya Zangbar
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Mazhar Khalil
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Peter Rhee
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Narong Kulvatunyou
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Andrew Tang
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Randall S Friese
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Terence O'Keeffe
- Division of Trauma, Critical Care, Burn and Emergency Surgery, Department of Surgery, University of Arizona, Tucson, Arizona.
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Zhang YP, Cai J, Shields LBE, Liu N, Xu XM, Shields CB. Traumatic brain injury using mouse models. Transl Stroke Res 2014; 5:454-71. [PMID: 24493632 DOI: 10.1007/s12975-014-0327-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 12/09/2013] [Accepted: 01/05/2014] [Indexed: 12/14/2022]
Abstract
The use of mouse models in traumatic brain injury (TBI) has several advantages compared to other animal models including low cost of breeding, easy maintenance, and innovative technology to create genetically modified strains. Studies using knockout and transgenic mice demonstrating functional gain or loss of molecules provide insight into basic mechanisms of TBI. Mouse models provide powerful tools to screen for putative therapeutic targets in TBI. This article reviews currently available mouse models that replicate several clinical features of TBI such as closed head injuries (CHI), penetrating head injuries, and a combination of both. CHI may be caused by direct trauma creating cerebral concussion or contusion. Sudden acceleration-deceleration injuries of the head without direct trauma may also cause intracranial injury by the transmission of shock waves to the brain. Recapitulation of temporary cavities that are induced by high-velocity penetrating objects in the mouse brain are difficult to produce, but slow brain penetration injuries in mice are reviewed. Synergistic damaging effects on the brain following systemic complications are also described. Advantages and disadvantages of CHI mouse models induced by weight drop, fluid percussion, and controlled cortical impact injuries are compared. Differences in the anatomy, biomechanics, and behavioral evaluations between mice and humans are discussed. Although the use of mouse models for TBI research is promising, further development of these techniques is warranted.
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Affiliation(s)
- Yi Ping Zhang
- Norton Neuroscience Institute, Norton Healthcare, 210 East Gray Street, Suite 1102, Louisville, KY, 40202, USA,
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33
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Alali AS, McCredie VA, Golan E, Shah PS, Nathens AB. Beta Blockers for Acute Traumatic Brain Injury: A Systematic Review and Meta-analysis. Neurocrit Care 2013; 20:514-23. [DOI: 10.1007/s12028-013-9903-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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