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Mansour NO, Elnaem MH, Abdelaziz DH, Barakat M, Dehele IS, Elrggal ME, Abdallah MS. Effects of early adjunctive pharmacotherapy on serum levels of brain injury biomarkers in patients with traumatic brain injury: a systematic review of randomized controlled studies. Front Pharmacol 2023; 14:1185277. [PMID: 37214454 PMCID: PMC10196026 DOI: 10.3389/fphar.2023.1185277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/14/2023] [Indexed: 05/24/2023] Open
Abstract
Objectives: Traumatic brain injury (TBI) is one of the top causes of morbidity and mortality worldwide. The review aimed to discuss and summarize the current evidence on the effectiveness of adjuvant neuroprotective treatments in terms of their effect on brain injury biomarkers in TBI patients. Methods: To identify relevant studies, four scholarly databases, including PubMed, Cochrane, Scopus, and Google Scholar, were systematically searched using predefined search terms. English-language randomized controlled clinical trials reporting changes in brain injury biomarkers, namely, neuron-specific enolase (NSE), glial fibrillary acid protein (GFAP), ubiquitin carboxyl-terminal esterase L1 (UCHL1) and/or S100 beta (S100 ß), were included. The methodological quality of the included studies was assessed using the Cochrane risk-of-bias tool. Results: A total of eleven studies with eight different therapeutic options were investigated; of them, tetracyclines, metformin, and memantine were discovered to be promising choices that could improve neurological outcomes in TBI patients. The most utilized serum biomarkers were NSE and S100 ß followed by GFAP, while none of the included studies quantified UCHL1. The heterogeneity in injury severity categories and measurement timing may affect the overall evaluation of the clinical efficacy of potential therapies. Therefore, unified measurement protocols are highly warranted to inform clinical decisions. Conclusion: Few therapeutic options showed promising results as an adjuvant to standard care in patients with TBI. Several considerations for future work must be directed towards standardizing monitoring biomarkers. Investigating the pharmacotherapy effectiveness using a multimodal biomarker panel is needed. Finally, employing stratified randomization in future clinical trials concerning potential confounders, including age, trauma severity levels, and type, is crucial to inform clinical decisions. Clinical Trial Registration: [https://www.crd.york.ac.uk/prospero/dis], identifier [CRD42022316327].
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Affiliation(s)
- Noha O. Mansour
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt
| | - Mohamed Hassan Elnaem
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Minden, Malaysia
- School of Pharmacy and Pharmaceutical Sciences, Ulster University, Coleraine, United Kingdom
| | - Doaa H. Abdelaziz
- Pharmacy Practice and Clinical Pharmacy Department, Faculty of Pharmacy, Future University in Egypt, Cairo, Egypt
| | - Muna Barakat
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
- MEU Research Unit, Middle East University, Amman, Jordan
| | | | | | - Mahmoud S. Abdallah
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Sadat City, Sadat City, Egypt
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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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Zheng Q, Duan D, Xu J, Wang X, Ge Y, Xiong L, Yang J, Wulayin S, Luo X. Comparative safety of multiple doses of erythropoietin for the treatment of traumatic brain injury: A systematic review and network meta-analysis. Front Neurol 2022; 13:998320. [PMID: 36582613 PMCID: PMC9793776 DOI: 10.3389/fneur.2022.998320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/21/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction Over the past few decades, advances in traumatic brain injury (TBI) pathology research have dynamically enriched our knowledge. Therefore, we aimed to systematically elucidate the safety and efficacy of erythropoietin (EPO) dosing regimens in patients with TBI. Methods Data search included PubMed, the Cochrane Library, Embase, Web of Science, and ClinicalTrials.gov for related research published before July 2022. The network meta-analysis was conducted using ADDIS 1.16.8, and the CINeMA tool was used to assess the quality level of evidence. Results A total of six RCTs involving 981 patients were included in the network meta-analysis. EPO did not significantly reduce mortality in patients with TBI, but its risk of death decreased with increasing dosage (odds ratio (OR) of 12,000u vs. placebo = 0.98, 95% CI: 0.03-40.34; OR of group 30,000u vs. placebo = 0.56, 95% CI: 0.06-5.88; OR of 40,000u vs. placebo = 0.35, 95% CI: 0.01-9.43; OR of 70,000u vs. placebo = 0.29, 95% CI: 0.01-9.26; OR of group 80,000u vs. placebo = 0.22, 95% CI: 0.00-7.45). A total of three studies involving 739 patients showed that EPO did not increase the incidence of deep vein thrombosis in patients with TBI. However, the risk tended to rise as the dosage increased. Another two studies demonstrated that EPO did not increase the incidence of pulmonary embolism. The quality of evidence for all outcomes was low to moderate. Conclusion Although the efficacy of EPO was not statistically demonstrated, we found a trend toward an association between EPO dosage and reduced mortality and increased embolic events in patients with TBI. More high-quality original studies should be conducted to obtain strong evidence on the optimal dosage of EPO. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=272500. The study protocol was registered with PROSPERO (CRD42021272500).
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Affiliation(s)
- Qingyong Zheng
- School of Public Health, Lanzhou University, Lanzhou, Gansu, China,Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, Gansu, China,Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
| | - Dan Duan
- Evidence-Based Nursing Center, School of Nursing, Lanzhou University, Lanzhou, Gansu, China
| | - Jianguo Xu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
| | - Xing Wang
- The First Clinical Medical College of Lanzhou University, Lanzhou, Gansu, China
| | - Yonggui Ge
- Department of Rehabilitation, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Lu Xiong
- School of Public Health, Lanzhou University, Lanzhou, Gansu, China
| | - Jingjing Yang
- The Second Clinical Medical College of Lanzhou University, Lanzhou, Gansu, China
| | - Saimire Wulayin
- The Second Clinical Medical College of Lanzhou University, Lanzhou, Gansu, China
| | - Xiaofeng Luo
- School of Public Health, Lanzhou University, Lanzhou, Gansu, China,*Correspondence: Xiaofeng Luo
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Li Y, Zhang J, Wang H, Zhu L, Zhang H, Ma Q, Liu X, Dong L, Lu G. Does erythropoietin affect the outcome and complication rates of patient with traumatic brain injury? A pooled-analysis. Neurol Sci 2022; 43:3783-3793. [PMID: 35044560 DOI: 10.1007/s10072-022-05877-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 01/08/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of this meta-analysis was to review the scientific literature published until April 18, 2021, to summarize existing knowledge on the efficacy and safety of erythropoietin (EPO) for traumatic brain injury (TBI). METHODS This systematic review followed PRISMA guidelines. Randomized controlled trials (RCTs) reporting on the efficacy and safety of EPO in the treatment of TBI were systematically searched in relevant electronic databases according to a pre-designed search strategy. The primary outcomes are the mortality; and secondary outcomes are the good functional outcome (GFO) and adverse events (AEs). RESULTS A total of 10 RCTs involving 2,402 participants fulfilled the inclusion criteria. The results showed that there is a significant difference in terms of the mortality (RR = 0.67, 95% CI = 0.54-0.84, P = 0.0003) and seizure rate (RR = 0.52, 95% CI = 0.29-0.96, P = 0.04) between the EPO groups compared to those in the control groups. However, compared with the control groups, the GFO in the EPO groups was not statistically significant (RR = 1.18, 95% CI = 0.93-1.48, P = 0.17). CONCLUSIONS Findings of the present meta-analysis suggest that the use of EPO could reduce mortality rate in patients with TBI, without increasing the incidence of AEs. EPO has potential research and application value in the treatment of TBI.
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Affiliation(s)
- Yuping Li
- Neuro Intensive Care Unit, Department of Neurosurgery, Clinical Medical College, Yangzhou University, Yangzhou, China.,Department of Neurosurgery, Yangzhou Clinical Medical College of Xuzhou Medical University, Xuzhou, China
| | - Jun Zhang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Haili Wang
- Department of Clinical Medicine, Dalian Medical University, Dalian Liaoning, China
| | - Lei Zhu
- Neuro Intensive Care Unit, Department of Neurosurgery, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Hengzhu Zhang
- Department of Neurosurgery, Yangzhou Clinical Medical College of Xuzhou Medical University, Xuzhou, China
| | - Qiang Ma
- Neuro Intensive Care Unit, Department of Neurosurgery, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Xiaoguang Liu
- Neuro Intensive Care Unit, Department of Neurosurgery, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Lun Dong
- Neuro Intensive Care Unit, Department of Neurosurgery, Clinical Medical College, Yangzhou University, Yangzhou, China.,Department of Neurosurgery, Yangzhou Clinical Medical College of Xuzhou Medical University, Xuzhou, China
| | - Guangyu Lu
- Institute of Public Health, Medical College, Yangzhou University, Yangzhou, China.
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Ma Y, Zhou Z, Yang GY, Ding J, Wang X. The Effect of Erythropoietin and Its Derivatives on Ischemic Stroke Therapy: A Comprehensive Review. Front Pharmacol 2022; 13:743926. [PMID: 35250554 PMCID: PMC8892214 DOI: 10.3389/fphar.2022.743926] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 01/19/2022] [Indexed: 12/17/2022] Open
Abstract
Numerous studies explored the therapeutic effects of erythropoietin (EPO) on neurodegenerative diseases. Few studies provided comprehensive and latest knowledge of EPO treatment for ischemic stroke. In the present review, we introduced the structure, expression, function of EPO, and its receptors in the central nervous system. Furthermore, we comprehensively discussed EPO treatment in pre-clinical studies, clinical trials, and its therapeutic mechanisms including suppressing inflammation. Finally, advanced studies of the therapy of EPO derivatives in ischemic stroke were also discussed. We wish to provide valuable information on EPO and EPO derivatives’ treatment for ischemic stroke for basic researchers and clinicians to accelerate the process of their clinical applications.
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Affiliation(s)
- Yuanyuan Ma
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhiyuan Zhou
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Yuan Yang
- Med-X Research Institute and School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Guo-Yuan Yang, ; Jing Ding,
| | - Jing Ding
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
- *Correspondence: Guo-Yuan Yang, ; Jing Ding,
| | - Xin Wang
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of The State Key Laboratory of Medical Neurobiology, The Institutes of Brain Science and the Collaborative Innovation Center for Brain Science, Fudan University, Shanghai, China
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Effect of erythropoietin administration on the expression of brain-derived neurotrophic factor, stromal cell-derived Factor-1, and neuron-specific enolase in traumatic brain injury: A literature review. Ann Med Surg (Lond) 2021; 69:102666. [PMID: 34429948 PMCID: PMC8371185 DOI: 10.1016/j.amsu.2021.102666] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 08/01/2021] [Accepted: 08/03/2021] [Indexed: 01/05/2023] Open
Abstract
Traumatic brain injury (TBI) is a major cause of death and lifelong disability around the world that predominantly affects young and middle-aged people. Erythropoietin (EPO) is a promising therapeutic agent for a variety of neurological injuries including TBI due to its neuroprotective effects. Here we review the impact of exogenous erythropoietin administration on the expression of brain-derived neurotrophic factor (BDNF), stromal cell-derived factor-1 (SDF-1), and neuron-specific enolase (NSE) levels in cerebrospinal fluid after TBI as biomarkers for neuron regeneration and survival to predict TBI outcome.
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7
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Potential Efficacy of Erythropoietin on Reducing the Risk of Mortality in Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:7563868. [PMID: 33178833 PMCID: PMC7644316 DOI: 10.1155/2020/7563868] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 10/09/2020] [Accepted: 10/15/2020] [Indexed: 01/28/2023]
Abstract
Objective The objective of this study is to assess the effectiveness of erythropoietin (EPO) on mortality, neurological outcomes, and adverse event in the treatment of traumatic brain injury (TBI). Methods We searched databases including PubMed, OVID, and the Cochrane Library from inception until October 18, 2019 for randomized controlled trials (RCTs) to compare EPO treatment group and placebo in patients with TBI. Two authors independently processed the data and evaluated the quality of inclusion studies. Statistical analysis was performed with heterogeneity test with I 2 and chi-square tests. We summarized the mortality, prognosis of neurological function, and deep vein thrombosis (DVT) outcomes and presented as risk ratio (RR) or risk difference (RD) with a 95% CI. Results Seven RCTs accounting for 1180 patients were included after meeting the inclusion criteria. Compared with placebo, the overall mortality of EPO-treated patients was significantly reduced (RR 0.68 [95% CI 0.50-0.93]; p = 0.02). EPO therapy did not improve neurological prognosis (RR 1.21 [95% CI 0.93-1.15]; p = 0.16) or increase the occurrence of DVT (RR 0.83 [95% CI 0.61-1.13]; p = 0.242), which showed no significant difference. Conclusions The results showed that the administration of EPO may reduce the risk of mortality without enhancing the occurrence of DVT in TBI patients. However, the effect of EPO on neurological outcome remains indistinct. Through subgroup analysis, we demonstrated that the dose of EPO may be a potential factor affecting the heterogeneity in neurological function and that the follow-up duration may influence the stability of the result.
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8
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Liu M, Wang AJ, Chen Y, Zhao G, Jiang Z, Wang X, Shi D, Zhang T, Sun B, He H, Williams Z, Hu K. Efficacy and safety of erythropoietin for traumatic brain injury. BMC Neurol 2020; 20:399. [PMID: 33138778 PMCID: PMC7604969 DOI: 10.1186/s12883-020-01958-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 10/14/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Recent studies regarding the effects of erythropoietin (EPO) for treating traumatic brain injury (TBI) have been inconsistent. This study conducts a meta-analysis of randomized controlled trials (RCTs) to assess the safety and efficacy of EPO for TBI patients at various follow-up time points. METHODS A literature search was performed using PubMed, Web of Science, MEDLINE, Embase, Google Scholar and the Cochrane Library for RCTs studying EPO in TBI patients published through March 2019. Non-English manuscripts and non-human studies were excluded. The assessed outcomes include mortality, neurological recovery and associated adverse effects. Dichotomous variables are presented as risk ratios (RR) with a 95% confidence interval (CI). RESULTS A total of seven RCTs involving 1197 TBI patients (611 treated with EPO, 586 treated with placebo) were included in this study. Compared to the placebo arm, treatment with EPO did not improve acute hospital mortality or short-term mortality. However, there was a significant improvement in mid-term (6 months) follow-up survival rates. EPO administration was not associated with neurological function improvement. Regarding adverse effects, EPO treatment did not increase the incidence of thromboembolic events or other associated adverse events. CONCLUSIONS This meta-analysis indicates a slight mortality benefit for TBI patients treated with EPO at mid-term follow-up. EPO does not improve in-hospital mortality, nor does it increase adverse events including thrombotic, cardiovascular and other associated complications. Our analysis did not demonstrate a significant beneficial effect of EPO intervention on the recovery of neurological function. Future RCTs are required to further characterize the use of EPO in TBI.
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Affiliation(s)
- Motao Liu
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No.197 Second Ruijin Street, Shanghai, 200025, China.,Center for Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.,Department of Biomedical Engineering, Columbia University, New York, NY, 10027, USA
| | - Amy J Wang
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Yu Chen
- Department of Orthopedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Gexin Zhao
- State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China
| | - Zhifeng Jiang
- Department of Neurosurgery, Ji Zhong Energy Fengfeng Group General hospital, Handan City, 056200, China
| | - Xinbang Wang
- Department of Neurosurgery, The PLA Navy Anqing Hospital, Anqing City, 246000, China
| | - Dongliang Shi
- Department of Neurosurgery, No.904th Hospital of The People's Liberation Army Joint Logistics Support Force, Wuxi, 214000, China
| | - Tiansong Zhang
- Department of Traditional Chinese Medicine, Jing-an District Central Hospital, Shanghai, 200437, China
| | - Bomin Sun
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No.197 Second Ruijin Street, Shanghai, 200025, China.,Center for Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Hua He
- Department of Neurosurgery, Third Affiliated Hospital, Second Military Medical University, Shanghai, 200438, China.
| | - Ziv Williams
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA.,MGH-HMS Center for Nervous System Repair, Harvard Medical School, Boston, MA, 02114, USA
| | - Kejia Hu
- Department of Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No.197 Second Ruijin Street, Shanghai, 200025, China. .,Center for Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China. .,Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA. .,MGH-HMS Center for Nervous System Repair, Harvard Medical School, Boston, MA, 02114, USA.
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Safety and efficacy of erythropoiesis-stimulating agents in critically ill patients admitted to the intensive care unit: a systematic review and meta-analysis. Intensive Care Med 2019; 45:1190-1199. [DOI: 10.1007/s00134-019-05686-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 07/03/2019] [Indexed: 12/27/2022]
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10
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Lee J, Cho Y, Choi KS, Kim W, Jang BH, Shin H, Ahn C, Lim TH, Yi HJ. Efficacy and safety of erythropoietin in patients with traumatic brain injury: A systematic review and meta-analysis. Am J Emerg Med 2019; 37:1101-1107. [PMID: 30220640 DOI: 10.1016/j.ajem.2018.08.072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate the effects of erythropoietin (EPO) on mortality and neurological outcomes in patients with traumatic brain injury (TBI). MATERIALS AND METHODS Electronic databases of studies published up to January 5, 2017 were searched to retrieve relevant investigations comparing the outcomes of EPO-treated patients and untreated patients following TBI. We calculated the relative risk (RR) of mortality, neurologic outcomes, and deep vein thrombosis (DVT) with corresponding 95% confidence interval (CI) using meta-analysis. RESULTS Six randomized controlled clinical trials met the eligibility criteria. In total, 1041 patients were included among the studies. EPO was found to significantly reduce the occurrence of mortality (RR 0.68 [95% CI 0.50-0.95]; P = 0.02), but did not significantly reduce poor functional outcome (RR 1.22 [95% CI 0.82-1.81]; P = 0.33). There were no significant differences in the occurrence of complications, such as DVT, between the treatment groups (RR -0.02 [95% CI -0.06-0.02]; P = 0.81). CONCLUSIONS Results of the present meta-analysis suggest that the use of EPO may prevent death following TBI without causing adverse events, such as deep vein thrombosis. However, the role of EPO in improving neurological outcome(s) remains unclear. Further well-designed, randomized controlled trials using modified protocols and involving specific patient populations are required to clarify this issue, and to verify the findings.
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Affiliation(s)
- Juncheol Lee
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Graduate School, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Youngsuk Cho
- Department of Emergency Medicine, College of Medicine, Hallym University, Seoul, Republic of Korea; Graduate School, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, College of Medicine, Hanyang University, Seoul, Republic of Korea.
| | - Wonhee Kim
- Department of Emergency Medicine, College of Medicine, Hallym University, Seoul, Republic of Korea
| | - Bo-Hyoung Jang
- Department of Preventive Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Hyungoo Shin
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea; Graduate School, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Chiwon Ahn
- Department of Emergency Medicine, Armed Forces Yangju Hospital, Yangju, Republic of Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Hyeong-Joong Yi
- Department of Neurosurgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
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Macias-Velez RJ, Fukushima-Díaz de León L, Beas-Zárate C, Rivera-Cervantes MC. Intranasal Erythropoietin Protects CA1 Hippocampal Cells, Modulated by Specific Time Pattern Molecular Changes After Ischemic Damage in Rats. J Mol Neurosci 2019; 68:590-602. [PMID: 31054091 DOI: 10.1007/s12031-019-01308-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/20/2019] [Indexed: 12/21/2022]
Abstract
Erythropoietin, a multitarget molecule exhibited neuroprotective properties, especially against cerebral ischemia. However, little effort has been made to determinate both the administration pathway and doses that diminishes neuronal damage. In this study, we investigate the effect on CA1 region of different intranasal doses of rHuEPO (500, 1000 and 2500 IU/kg) applied in distinct post-damage times (1, 6, and 24 h) against ischemic cellular damage. Furthermore, most effective dose and time were used to evaluate gen and protein expression changes in 3 key molecules (EPO, EPOR, and βcR). We established that CA1-region present histopathological damage in this ischemia model and that rHuEPO protects cells against damage, particularly at 1000 IU dose. Molecular data shows that EPO and EPOR gene expression are upregulated in a short term after damage treatment with rHuEPO (1 h); oppositely, BcR is upregulated in ischemic and Isc + EPO. Protein expression data displays no changes on EPO expression in evaluated times after treatment, but a tendency to increase 24 h after damage; in the opposite way, EPOR is upregulated significantly 6 h after treatment and this effect last until 24 h. So, our data suggest that a single intranasal dose of rHuEPO (1 h post-injury) provides histological neurorestoration in CA1 hippocampal region, even if we did not observe a dose-dependent dose effect, the medium dose evaluated (1000 UI/kg of b.w.) was more effective and sufficient for induces molecular changes that provides a platform for neuroprotection.
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Affiliation(s)
- R J Macias-Velez
- Laboratorio de Neurobiología Celular, Departamento de Biología Celular y Molecular, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - L Fukushima-Díaz de León
- Laboratorio de Neurobiología Celular, Departamento de Biología Celular y Molecular, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - C Beas-Zárate
- Laboratorio de Regeneración Neural y Desarrollo Neural, Departamento de Biología Celular y Molecular, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - M C Rivera-Cervantes
- Laboratorio de Neurobiología Celular, Departamento de Biología Celular y Molecular, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico.
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12
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Affiliation(s)
- Yongli He
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhiyou Cai
- Department of Neurology, Chongqing General Hospital, Chongqing, China
| | - Yangmei Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Mesgarpour B, Heidinger BH, Roth D, Schmitz S, Walsh CD, Herkner H. Harms of off-label erythropoiesis-stimulating agents for critically ill people. Cochrane Database Syst Rev 2017; 8:CD010969. [PMID: 28841235 PMCID: PMC6373621 DOI: 10.1002/14651858.cd010969.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Anaemia is a common problem experienced by critically-ill people. Treatment with erythropoiesis-stimulating agents (ESAs) has been used as a pharmacologic strategy when the blunted response of endogenous erythropoietin has been reported in critically-ill people. The use of ESAs becomes more important where adverse clinical outcomes of transfusing blood products is a limitation. However, this indication for ESAs is not licensed by regulatory authorities and is called off-label use. Recent studies concern the harm of ESAs in a critical care setting. OBJECTIVES To focus on harms in assessing the effects of erythropoiesis-stimulating agents (ESAs), alone or in combination, compared with placebo, no treatment or a different active treatment regimen when administered off-label to critically-ill people. SEARCH METHODS We conducted a systematic search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO via OvidSP, CINAHL, all evidence-based medicine (EBM) reviews including IPA and SCI-Expanded, Conference Proceedings Citation Index- Science, BIOSIS Previews and TOXLINE up to February 2017. We also searched trials registries, checked reference lists of relevant studies and tracked their citations by using SciVerse Scopus. SELECTION CRITERIA We considered randomized controlled trials (RCTs) and controlled observational studies, which compared scheduled systemic administration of ESAs versus other effective interventions, placebo or no treatment in critically-ill people. DATA COLLECTION AND ANALYSIS Two review authors independently screened and evaluated the eligibility of retrieved records, extracted data and assessed the risks of bias and quality of the included studies. We resolved differences in opinion by consensus or by involving a third review author. We assessed the evidence using GRADE and created a 'Summary of findings' table. We used fixed-effect or random-effects models, depending on the heterogeneity between studies. We fitted three-level hierarchical Bayesian models to calculate overall treatment effect estimates. MAIN RESULTS Of the 27,865 records identified, 39 clinical trials and 14 observational studies, including a total of 945,240 participants, were eligible for inclusion. Five studies are awaiting classification. Overall, we found 114 adverse events in 33 studies (30 RCTs and three observational studies), and mortality was reported in 41 studies (32 RCTs and nine observational studies). Most studies were at low to moderate risk of bias for harms outcomes. However, overall harm assessment and reporting were of moderate to low quality in the RCTs, and of low quality in the observational studies. We downgraded the GRADE quality of evidence for venous thromboembolism and mortality to very low and low, respectively, because of risk of bias, high inconsistency, imprecision and limitations of study design.It is unclear whether there is an increase in the risk of any adverse events (Bayesian risk ratio (RR) 1.05, 95% confidence interval (CI) 0.93 to 1.21; 3099 participants; 9 studies; low-quality evidence) or venous thromboembolism (Bayesian RR 1.04, 95% CI 0.70 to 1.41; 18,917 participants; 18 studies; very low-quality evidence).There was a decreased risk of mortality with off-label use of ESAs in critically-ill people (Bayesian RR 0.76, 95% CI 0.61 to 0.92; 930,470 participants; 34 studies; low-quality evidence). AUTHORS' CONCLUSIONS Low quality of evidence suggests that off-label use of ESAs may reduce mortality in a critical care setting. There was a lack of high-quality evidence about the harm of ESAs in critically-ill people. The information for biosimilar ESAs is less conclusive. Most studies neither evaluated ESAs' harm as a primary outcome nor predefined adverse events. Any further studies of ESA should address the quality of evaluating, recording and reporting of adverse events.
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Affiliation(s)
| | | | - Dominik Roth
- Medical University of ViennaDepartment of Emergency MedicineAllgemeines Krankenhaus, Währinger Gürtel
18‐20,ViennaAustria1090
| | - Susanne Schmitz
- Luxembourg Institute of HealthDepartment of Population Health1A‐B, rue Thomas EdisonStrassenLuxembourg1445
| | - Cathal D Walsh
- Department of Mathematics and StatisticsHealth Research Institute (HRI) and MACSIUniversity of LimerickIreland
| | - Harald Herkner
- Medical University of ViennaDepartment of Emergency MedicineAllgemeines Krankenhaus, Währinger Gürtel
18‐20,ViennaAustria1090
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Joseph B, Khan M, Rhee P. Non-invasive diagnosis and treatment strategies for traumatic brain injury: an update. J Neurosci Res 2017; 96:589-600. [PMID: 28836292 DOI: 10.1002/jnr.24132] [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] [Received: 01/25/2017] [Revised: 06/26/2017] [Accepted: 07/10/2017] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Traumatic Brain Injury (TBI) remains the leading cause of morbidity and mortality in U.S. Since the last decade, there have been several advances in the understanding and management of TBI that have shown the potential to improve outcomes. The aim of this review is to provide a useful overview of these potential diagnostic and treatment strategies that have yet to be proven, along with an assessment of their impact on outcomes after a TBI. RECENT FINDINGS Recent technical advances in the management of a TBI are grounded in a better understanding of the pathophysiology of primary and secondary insult to the brain after a TBI. Hence, clinical trials on humans should proceed in order to evaluate their efficacy and safety. SUMMARY Mortality associated with TBI remains high. Nonetheless, new diagnostic and therapeutic techniques have the potential to enhance early detection and prevention of secondary brain insult.
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Affiliation(s)
- Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona, USA
| | - Muhammad Khan
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona, USA
| | - Peter Rhee
- Division of Acute Care Surgery, Department of Surgery, Grady Memorial Hospital, Atlanta, Georgia, USA
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Thelin EP, Zeiler FA, Ercole A, Mondello S, Büki A, Bellander BM, Helmy A, Menon DK, Nelson DW. Serial Sampling of Serum Protein Biomarkers for Monitoring Human Traumatic Brain Injury Dynamics: A Systematic Review. Front Neurol 2017; 8:300. [PMID: 28717351 PMCID: PMC5494601 DOI: 10.3389/fneur.2017.00300] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 06/12/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The proteins S100B, neuron-specific enolase (NSE), glial fibrillary acidic protein (GFAP), ubiquitin carboxy-terminal hydrolase L1 (UCH-L1), and neurofilament light (NF-L) have been serially sampled in serum of patients suffering from traumatic brain injury (TBI) in order to assess injury severity and tissue fate. We review the current literature of serum level dynamics of these proteins following TBI and used the term "effective half-life" (t1/2) in order to describe the "fall" rate in serum. MATERIALS AND METHODS Through searches on EMBASE, Medline, and Scopus, we looked for articles where these proteins had been serially sampled in serum in human TBI. We excluded animal studies, studies with only one presented sample and studies without neuroradiological examinations. RESULTS Following screening (10,389 papers), n = 122 papers were included. The proteins S100B (n = 66) and NSE (n = 27) were the two most frequent biomarkers that were serially sampled. For S100B in severe TBI, a majority of studies indicate a t1/2 of about 24 h, even if very early sampling in these patients reveals rapid decreases (1-2 h) though possibly of non-cerebral origin. In contrast, the t1/2 for NSE is comparably longer, ranging from 48 to 72 h in severe TBI cases. The protein GFAP (n = 18) appears to have t1/2 of about 24-48 h in severe TBI. The protein UCH-L1 (n = 9) presents a t1/2 around 7 h in mild TBI and about 10 h in severe. Frequent sampling of these proteins revealed different trajectories with persisting high serum levels, or secondary peaks, in patients with unfavorable outcome or in patients developing secondary detrimental events. Finally, NF-L (n = 2) only increased in the few studies available, suggesting a serum availability of >10 days. To date, automated assays are available for S100B and NSE making them faster and more practical to use. CONCLUSION Serial sampling of brain-specific proteins in serum reveals different temporal trajectories that should be acknowledged. Proteins with shorter serum availability, like S100B, may be superior to proteins such as NF-L in detection of secondary harmful events when monitoring patients with TBI.
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Affiliation(s)
- Eric Peter Thelin
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Frederick Adam Zeiler
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Clinician Investigator Program, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - András Büki
- Szentagothai Research Centre, University of Pecs, Pecs, Hungary
- Department of Neurosurgery, University of Pecs, Pecs, Hungary
- MTA-PTE Clinical Neuroscience MR Research Group, Pecs, Hungary
| | | | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - David K. Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - David W. Nelson
- Section of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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17
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Grasso G, Alafaci C, Ghezzi P. Is erythropoietin a worthy candidate for traumatic brain injury or are we heading the wrong way? F1000Res 2016; 5:911. [PMID: 27239280 PMCID: PMC4879931 DOI: 10.12688/f1000research.8723.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2016] [Indexed: 01/23/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability in the modern society. Although primary prevention is the only strategy that can counteract the primary brain damage, numerous preclinical studies have been accumulated in order to find therapeutic strategies against the secondary damage. In this scenario erythropoietin (EPO) has been shown to be a promising candidate as neuroprotective agent. A recent clinical trial, however, has shown that EPO has not an overall effect on outcomes following TBI thus renewing old concerns. However, the results of a prespecified sensitivity analysis indicate that the effect of EPO on mortality remains still unclear. In the light of these observations, further investigations are needed to resolve doubts on EPO effectiveness in order to provide a more solid base for tailoring conclusive clinical trials.
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Affiliation(s)
- Giovanni Grasso
- Section of Neurosurgery, Department of Experimental Biomedicine and Clinical Neurosciences (BIONEC), University of Palermo, Palermo, 90100, Italy
| | - Concetta Alafaci
- Department of Neurosurgery, University of Messina, Messina, 98100, Italy
| | - Pietro Ghezzi
- Brighton and Sussex Medical School, Falmer, BN1 9PX, UK
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18
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de Rivero Vaccari JP, Dietrich WD, Keane RW. Therapeutics targeting the inflammasome after central nervous system injury. Transl Res 2016; 167:35-45. [PMID: 26024799 PMCID: PMC4643411 DOI: 10.1016/j.trsl.2015.05.003] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 04/20/2015] [Accepted: 05/05/2015] [Indexed: 12/15/2022]
Abstract
Innate immunity is part of the early response of the body to deal with tissue damage and infections. Because of the early nature of the innate immune inflammatory response, this inflammatory reaction represents an attractive option as a therapeutic target. The inflammasome is a component of the innate immune response involved in the activation of caspase 1 and the processing of pro-interleukin 1β. In this article, we discuss the therapeutic potential of the inflammasome after central nervous system (CNS) injury and stroke, as well as the basic knowledge we have gained so far regarding inflammasome activation in the CNS. In addition, we discuss some of the therapies available or under investigation for the treatment of brain injury, spinal cord injury, and stroke.
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Affiliation(s)
- Juan Pablo de Rivero Vaccari
- Department of Neurological Surgery, Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Fla.
| | - W Dalton Dietrich
- Department of Neurological Surgery, Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Fla
| | - Robert W Keane
- Department of Neurological Surgery, Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Fla; Department of Physiology and Biophysics, University of Miami Miller School of Medicine, Miami, Fla
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19
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Bergold PJ. Treatment of traumatic brain injury with anti-inflammatory drugs. Exp Neurol 2015; 275 Pt 3:367-380. [PMID: 26112314 DOI: 10.1016/j.expneurol.2015.05.024] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 05/13/2015] [Accepted: 05/17/2015] [Indexed: 12/31/2022]
Abstract
Traumatic brain injury rapidly induces inflammation. This inflammation is produced both by endogenous brain cells and circulating inflammatory cells that enter from the brain. Together they drive the inflammatory response through a wide variety of bioactive lipids, cytokines and chemokines. A large number of drugs with anti-inflammatory action have been tested in both preclinical studies and in clinical trials. These drugs either have known anti-inflammatory action or inhibit the inflammatory response through unknown mechanisms. The results of these preclinical studies and clinical trials are reviewed. Recommendations are suggested on how to improve preclinical testing of drugs to make them more relevant to evaluate for clinical trials.
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Affiliation(s)
- Peter J Bergold
- Robert F. Furchgott Center for Neural Science, Department of Physiology and Pharmacology, SUNY-Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, United States.
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20
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Robertson CS, Hannay HJ, Yamal JM, Gopinath S, Goodman JC, Tilley BC, Baldwin A, Rivera Lara L, Saucedo-Crespo H, Ahmed O, Sadasivan S, Ponce L, Cruz-Navarro J, Shahin H, Aisiku IP, Doshi P, Valadka A, Neipert L, Waguspack JM, Rubin ML, Benoit JS, Swank P. Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial. JAMA 2014; 312:36-47. [PMID: 25058216 PMCID: PMC4113910 DOI: 10.1001/jama.2014.6490] [Citation(s) in RCA: 333] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE There is limited information about the effect of erythropoietin or a high hemoglobin transfusion threshold after a traumatic brain injury. OBJECTIVE To compare the effects of erythropoietin and 2 hemoglobin transfusion thresholds (7 and 10 g/dL) on neurological recovery after traumatic brain injury. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 200 patients (erythropoietin, n = 102; placebo, n = 98) with closed head injury who were unable to follow commands and were enrolled within 6 hours of injury at neurosurgical intensive care units in 2 US level I trauma centers between May 2006 and August 2012. The study used a factorial design to test whether erythropoietin would fail to improve favorable outcomes by 20% and whether a hemoglobin transfusion threshold of greater than 10 g/dL would increase favorable outcomes without increasing complications. Erythropoietin or placebo was initially dosed daily for 3 days and then weekly for 2 more weeks (n = 74) and then the 24- and 48-hour doses were stopped for the remainder of the patients (n = 126). There were 99 patients assigned to a hemoglobin transfusion threshold of 7 g/dL and 101 patients assigned to 10 g/dL. INTERVENTIONS Intravenous erythropoietin (500 IU/kg per dose) or saline. Transfusion threshold maintained with packed red blood cells. MAIN OUTCOMES AND MEASURES Glasgow Outcome Scale score dichotomized as favorable (good recovery and moderate disability) or unfavorable (severe disability, vegetative, or dead) at 6 months postinjury. RESULTS There was no interaction between erythropoietin and hemoglobin transfusion threshold. Compared with placebo (favorable outcome rate: 34/89 [38.2%; 95% CI, 28.1% to 49.1%]), both erythropoietin groups were futile (first dosing regimen: 17/35 [48.6%; 95% CI, 31.4% to 66.0%], P = .13; second dosing regimen: 17/57 [29.8%; 95% CI, 18.4% to 43.4%], P < .001). Favorable outcome rates were 37/87 (42.5%) for the hemoglobin transfusion threshold of 7 g/dL and 31/94 (33.0%) for 10 g/dL (95% CI for the difference, -0.06 to 0.25, P = .28). There was a higher incidence of thromboembolic events for the transfusion threshold of 10 g/dL (22/101 [21.8%] vs 8/99 [8.1%] for the threshold of 7 g/dL, odds ratio, 0.32 [95% CI, 0.12 to 0.79], P = .009). CONCLUSIONS AND RELEVANCE In patients with closed head injury, neither the administration of erythropoietin nor maintaining hemoglobin concentration of greater than 10 g/dL resulted in improved neurological outcome at 6 months. The transfusion threshold of 10 g/dL was associated with a higher incidence of adverse events. These findings do not support either approach in this setting. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00313716.
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Affiliation(s)
| | - H Julia Hannay
- Department of Psychology, University of Houston, Houston, Texas
| | - José-Miguel Yamal
- Division of Biostatistics, University of Texas Health Science Center at Houston School of Public Health, Houston
| | - Shankar Gopinath
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - J Clay Goodman
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas
| | - Barbara C Tilley
- Division of Biostatistics, University of Texas Health Science Center at Houston School of Public Health, Houston
| | | | - Athena Baldwin
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Lucia Rivera Lara
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Osama Ahmed
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Luciano Ponce
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Hazem Shahin
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Pratik Doshi
- University of Texas Health Sciences Center, Houston
| | - Alex Valadka
- University of Texas Health Sciences Center, Houston
| | - Leslie Neipert
- Department of Psychology, University of Houston, Houston, Texas
| | | | - M Laura Rubin
- Division of Biostatistics, University of Texas Health Science Center at Houston School of Public Health, Houston
| | - Julia S Benoit
- Division of Biostatistics, University of Texas Health Science Center at Houston School of Public Health, Houston
| | - Paul Swank
- Division of Biostatistics, University of Texas Health Science Center at Houston School of Public Health, Houston
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21
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Kabadi SV, Faden AI. Neuroprotective strategies for traumatic brain injury: improving clinical translation. Int J Mol Sci 2014; 15:1216-36. [PMID: 24445258 PMCID: PMC3907865 DOI: 10.3390/ijms15011216] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 01/07/2014] [Accepted: 01/13/2014] [Indexed: 01/15/2023] Open
Abstract
Traumatic brain injury (TBI) induces secondary biochemical changes that contribute to delayed neuroinflammation, neuronal cell death, and neurological dysfunction. Attenuating such secondary injury has provided the conceptual basis for neuroprotective treatments. Despite strong experimental data, more than 30 clinical trials of neuroprotection in TBI patients have failed. In part, these failures likely reflect methodological differences between the clinical and animal studies, as well as inadequate pre-clinical evaluation and/or trial design problems. However, recent changes in experimental approach and advances in clinical trial methodology have raised the potential for successful clinical translation. Here we critically analyze the current limitations and translational opportunities for developing successful neuroprotective therapies for TBI.
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Affiliation(s)
- Shruti V Kabadi
- Department of Anesthesiology, Center for Shock, Trauma and Anesthesiology Research (STAR), National Study Center for Trauma and EMS, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Alan I Faden
- Department of Anesthesiology, Center for Shock, Trauma and Anesthesiology Research (STAR), National Study Center for Trauma and EMS, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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22
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Bednar MM, Perry A. Neurorestoration therapeutics for neurodegenerative and psychiatric disease. Neurol Res 2013; 34:129-42. [DOI: 10.1179/1743132811y.0000000069] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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23
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Radosevich JJ, Patanwala AE, Erstad BL. Emerging pharmacological agents to improve survival from traumatic brain injury. Brain Inj 2013; 27:1492-9. [DOI: 10.3109/02699052.2013.823658] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Anderson GD, Peterson TC, Vonder Haar C, Kantor ED, Farin FM, Bammler TK, Macdonald JW, Hoane MR. Comparison of the effects of erythropoietin and anakinra on functional recovery and gene expression in a traumatic brain injury model. Front Pharmacol 2013; 4:129. [PMID: 24151467 PMCID: PMC3798024 DOI: 10.3389/fphar.2013.00129] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 09/24/2013] [Indexed: 11/13/2022] Open
Abstract
The goal of this study was to compare the effects of two inflammatory modulators, erythropoietin (EPO) and anakinra, on functional recovery and brain gene expression following a cortical contusion impact (CCI) injury. Dosage regimens were designed to provide serum concentrations in the range obtained with clinically approved doses. Functional recovery was assessed using both motor and spatial learning tasks and neuropathological measurements conducted in the cortex and hippocampus. Microarray-based transcriptional profiling was used to determine the effect on gene expression at 24 h, 72 h, and 7 days post-CCI. Ingenuity Pathway Analysis was used to evaluate the effect on relevant functional categories. EPO and anakinra treatment resulted in significant changes in brain gene expression in the CCI model demonstrating acceptable brain penetration. At all three time points, EPO treatment resulted in significantly more differentially expressed genes than anakinra. For anakinra at 24 h and EPO at 24 h, 72 h, and 7 days, the genes in the top 3 functional categories were involved in cellular movement, inflammatory response and cell-to-cell signaling. For EPO, the majority of the genes in the top 10 canonical pathways identified were associated with inflammatory and immune signaling processes. This was true for anakinra only at 24 h post-traumatic brain injury (TBI). The immunomodulation effects of EPO and anakinra did not translate into positive effects on functional behavioral and lesion studies. Treatment with either EPO or anakinra failed to induce significant beneficial effects on recovery of function or produce any significant effects on the prevention of injury induced tissue loss at 30 days post-injury. In conclusion, treatment with EPO or anakinra resulted in significant effects on gene expression in the brain without affecting functional outcome. This suggests that targeting these inflammatory processes alone may not be sufficient for preventing secondary injuries after TBI.
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Affiliation(s)
- Gail D Anderson
- Department of Pharmacy, University of Washington Seattle, WA, USA
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25
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Meng Y, Xiong Y, Mahmood A, Zhang Y, Qu C, Chopp M. Dose-dependent neurorestorative effects of delayed treatment of traumatic brain injury with recombinant human erythropoietin in rats. J Neurosurg 2011; 115:550-60. [PMID: 21495821 DOI: 10.3171/2011.3.jns101721] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECT Delayed (24 hours postinjury) treatment with erythropoietin (EPO) improves functional recovery following experimental traumatic brain injury (TBI). In this study, the authors tested whether therapeutic effects of delayed EPO treatment for TBI are dose dependent in an attempt to establish an optimal dose paradigm for the delayed EPO treatment. METHODS Experimental TBI was performed in anesthetized young adult male Wistar rats using a controlled cortical impact device. Sham animals underwent the same surgical procedure without injury. The animals (8 rats/group) received 3 intraperitoneal injections of EPO (0, 1000, 3000, 5000, or 7000 U/kg body weight, at 24, 48, and 72 hours) after TBI. Sensorimotor and cognitive functions were assessed using a modified neurological severity score and foot fault test, and Morris water maze tests, respectively. Animals were killed 35 days after injury, and the brain sections were stained for immunohistochemical analyses. RESULTS Compared with the saline treatment, EPO treatment at doses from 1000 to 7000 U/kg did not alter lesion volume but significantly reduced hippocampal neuron loss, enhanced angiogenesis and neurogenesis in the injured cortex and hippocampus, and significantly improved sensorimotor function and spatial learning. The animals receiving the medium dose of 5000 U/kg exhibited a significant improvement in histological and functional outcomes compared with the lower or higher EPO dose groups. CONCLUSIONS These data demonstrate that delayed (24 hours postinjury) treatment with EPO provides dose-dependent neurorestoration, which may contribute to improved functional recovery after TBI, implying that application of an optimal dose of EPO is likely to increase successful preclinical and clinical trials for treatment of TBI.
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Affiliation(s)
- Yuling Meng
- Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan 48202, USA
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26
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Ozden H, Durmaz R, Kanbak G, Uzuner K, Aral E, Kartkaya K, Kabay SC, Atasoy MA. Erythropoietin prevents nitric oxide and cathepsin-mediated neuronal death in focal brain ischemia. Brain Res 2010; 1370:185-93. [PMID: 21108937 DOI: 10.1016/j.brainres.2010.11.045] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Revised: 11/06/2010] [Accepted: 11/10/2010] [Indexed: 11/27/2022]
Abstract
We examined the preventive effect of human recombinant erythropoietin (HrEPO) on nitric oxide (NO)-mediated toxicity to neurons and cysteine protease release into cytoplasm, which is attributed to neuronal death in brain ischemia. Focal cerebral ischemia was induced by permanent occlusion of middle cerebral artery in two sets of rat. The first set was used to monitor NO concentration and cathepsin activity, while the second was used for histological examination with hematoxylin and eosin, and TUNEL staining. A group in both set was administered human recombinant erythropoietin (HrEPO). NO content, cathepsins B and L activity increased significantly in the post-ischemic cerebral tissue (p<0.05). HrEPO treatment reduced NO concentration and cathepsin activity to control level (p>0.05). A significant increase in the number of necrotic and apoptotic neurons was observed in the post-ischemic cerebral cortex (p<0.05). HrEPO treatment was markedly lowered both of these (p<0.05). It is concluded that HrEPO prevents neuronal death by protecting neuronal liposomes from NO-mediated toxicity and suppressing the release of cathepsins.
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Affiliation(s)
- Hilmi Ozden
- Department of Anatomy, Eskişehir Osmangazi University School of Medicine, 26480 Eskişehir, Turkey.
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