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Leone R, Zuglian C, Brambilla R, Morella I. Understanding copy number variations through their genes: a molecular view on 16p11.2 deletion and duplication syndromes. Front Pharmacol 2024; 15:1407865. [PMID: 38948459 PMCID: PMC11211608 DOI: 10.3389/fphar.2024.1407865] [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: 03/27/2024] [Accepted: 05/16/2024] [Indexed: 07/02/2024] Open
Abstract
Neurodevelopmental disorders (NDDs) include a broad spectrum of pathological conditions that affect >4% of children worldwide, share common features and present a variegated genetic origin. They include clinically defined diseases, such as autism spectrum disorders (ASD), attention-deficit/hyperactivity disorder (ADHD), motor disorders such as Tics and Tourette's syndromes, but also much more heterogeneous conditions like intellectual disability (ID) and epilepsy. Schizophrenia (SCZ) has also recently been proposed to belong to NDDs. Relatively common causes of NDDs are copy number variations (CNVs), characterised by the gain or the loss of a portion of a chromosome. In this review, we focus on deletions and duplications at the 16p11.2 chromosomal region, associated with NDDs, ID, ASD but also epilepsy and SCZ. Some of the core phenotypes presented by human carriers could be recapitulated in animal and cellular models, which also highlighted prominent neurophysiological and signalling alterations underpinning 16p11.2 CNVs-associated phenotypes. In this review, we also provide an overview of the genes within the 16p11.2 locus, including those with partially known or unknown function as well as non-coding RNAs. A particularly interesting interplay was observed between MVP and MAPK3 in modulating some of the pathological phenotypes associated with the 16p11.2 deletion. Elucidating their role in intracellular signalling and their functional links will be a key step to devise novel therapeutic strategies for 16p11.2 CNVs-related syndromes.
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Affiliation(s)
- Roberta Leone
- Università di Pavia, Dipartimento di Biologia e Biotecnologie “Lazzaro Spallanzani”, Pavia, Italy
| | - Cecilia Zuglian
- Università di Pavia, Dipartimento di Biologia e Biotecnologie “Lazzaro Spallanzani”, Pavia, Italy
| | - Riccardo Brambilla
- Università di Pavia, Dipartimento di Biologia e Biotecnologie “Lazzaro Spallanzani”, Pavia, Italy
- Cardiff University, School of Biosciences, Neuroscience and Mental Health Innovation Institute, Cardiff, United Kingdom
| | - Ilaria Morella
- Cardiff University, School of Biosciences, Neuroscience and Mental Health Innovation Institute, Cardiff, United Kingdom
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Malloy DC, Côté MP. Multi-session transcutaneous spinal cord stimulation prevents chloride homeostasis imbalance and the development of hyperreflexia after spinal cord injury in rat. Exp Neurol 2024; 376:114754. [PMID: 38493983 DOI: 10.1016/j.expneurol.2024.114754] [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: 12/01/2023] [Revised: 02/28/2024] [Accepted: 03/11/2024] [Indexed: 03/19/2024]
Abstract
Spasticity is a complex and multidimensional disorder that impacts nearly 75% of individuals with spinal cord injury (SCI) and currently lacks adequate treatment options. This sensorimotor condition is burdensome as hyperexcitability of reflex pathways result in exacerbated reflex responses, co-contractions of antagonistic muscles, and involuntary movements. Transcutaneous spinal cord stimulation (tSCS) has become a popular tool in the human SCI research field. The likeliness for this intervention to be successful as a noninvasive anti-spastic therapy after SCI is suggested by a mild and transitory improvement in spastic symptoms following a single stimulation session, but it remains to be determined if repeated tSCS over the course of weeks can produce more profound effects. Despite its popularity, the neuroplasticity induced by tSCS also remains widely unexplored, particularly due to the lack of suitable animal models to investigate this intervention. Thus, the basis of this work was to use tSCS over multiple sessions (multi-session tSCS) in a rat model to target spasticity after SCI and identify the long-term physiological improvements and anatomical neuroplasticity occurring in the spinal cord. Here, we show that multi-session tSCS in rats with an incomplete (severe T9 contusion) SCI (1) decreases hyperreflexia, (2) increases the low frequency-dependent modulation of the H-reflex, (3) prevents potassium-chloride cotransporter isoform 2 (KCC2) membrane downregulation in lumbar motoneurons, and (4) generally augments motor output, i.e., EMG amplitude in response to single pulses of tSCS, particularly in extensor muscles. Together, this work displays that multi-session tSCS can target and diminish spasticity after SCI as an alternative to pharmacological interventions and begins to highlight the underlying neuroplasticity contributing to its success in improving functional recovery.
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Affiliation(s)
- Dillon C Malloy
- Marion Murray Spinal Cord Research Center, Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, United States of America.
| | - Marie-Pascale Côté
- Marion Murray Spinal Cord Research Center, Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, United States of America.
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Săndulescu MI, Cinteză D, Poenaru D, Potcovaru CG, Păunescu H, Coman OA. The Complex Role of Botulinum Toxin in Enhancing Goal Achievement for Post-Stroke Patients. Toxins (Basel) 2024; 16:172. [PMID: 38668597 PMCID: PMC11054582 DOI: 10.3390/toxins16040172] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/14/2024] [Accepted: 03/16/2024] [Indexed: 04/29/2024] Open
Abstract
INTRODUCTION The rehabilitation medical team is responsible for the therapeutic management of post-stroke patients and, therefore, for the complex therapeutic approach of spasticity. Considering the generous arsenal at our disposal in terms of both pharmacological treatment, through the possibility of administering botulinum toxin to combat spasticity, and in terms of accurate assessment through developed functional scales such as the GAS (Goal Attainment Scale), one of our purposes is to monitor the parameters that influence the achievement of functional goals set by patients together with the medical team in order to render the patients as close as possible to achieving their proposed functional goals, thus enhancing their quality of life. By assessing and establishing statistical and clinical correlations between the GAS and quantifiable parameters related to the affected post-stroke upper limb, namely degree of spasticity, motor control, pain level and evolution of pain under treatment with BoNT-A (abobotulinum toxin A), and patients' overall response to BoNT-A treatment, we aim to quantify the improvement of the therapeutic management of post-stroke patients with spasticity and develop a more personalized and effective approach to their disability and impairment. RESULTS AND DISCUSSIONS The analysis concluded that there were two independent predictors of the Achieved GAS-T score (the study's endpoint parameter) motor control at any level of the upper limb and number of prior BoNT-A injections. The number of prior BoNT-A injections was an independent predictor of Achieved GAS-T score improvement but had no significant influence over Baseline GAS-T score. Enhancement in proximal and intermediate motor control showed a GAS score improvement of 3.3 points and a 0.93-point GAS score improvement for wrist motor control progress. From a separate viewpoint, patients with motor deficit on the left side have shown significantly greater improvement in Changed GAS-T scores by 2.5 points compared to patients with deficits on the right side; however, we note as a study limitation the fact that there was no statistical analysis over the dominant cerebral hemisphere of each patient. CONCLUSIONS Improvement in the Achieved GAS-T score means better achievement of patients' goals. Thus, after the BoNT- A intervention, at follow-up evaluation, GAS was found to be directly correlated with improvement in motor control of the affected upper limb. Mobility of the corresponding limb was enhanced by pain decrease during p-ROM (passive range of motion) and by amelioration of spasticity. MATERIALS AND METHODS We conducted an observational, non-randomized clinical study on 52 stroke patients, a representative sample of patients with post-stroke spasticity and disability from our neurological rehabilitation clinic, who have been treated and undergone a specific rehabilitation program in our tertiary diagnostic and treatment medical center, including BoNT-A focal treatment for spasticity in the affected upper limb. The primary objective of the study was to assess the influence of abobotulinum toxin A treatment on the Goal Attainment Scale. Secondary objectives of the study included the assessment of BoNT-A treatment efficacy on spasticity with the MAS (Modified Ashworth Scale), pain with the NRS (Numerical Rating Scale), and joint passive range of motion (p-ROM), identifying demographic, clinical, and pharmacological factors that influence the response to BoNT-A treatment, as well as to conduct a descriptive and exploratory analysis of the studied variables.
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Affiliation(s)
- Miruna Ioana Săndulescu
- Doctoral School, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (D.P.); (H.P.); (O.A.C.)
- Rehabilitation Department 9, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Pharmacology and Pharmacotherapy, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- National Institute of Rehabilitation, Physical Medicine and Balneo-Climatology, 010024 Bucharest, Romania
| | - Delia Cinteză
- Doctoral School, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (D.P.); (H.P.); (O.A.C.)
- Rehabilitation Department 9, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- National Institute of Rehabilitation, Physical Medicine and Balneo-Climatology, 010024 Bucharest, Romania
| | - Daniela Poenaru
- Doctoral School, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (D.P.); (H.P.); (O.A.C.)
- Rehabilitation Department 9, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- National Institute of Rehabilitation, Physical Medicine and Balneo-Climatology, 010024 Bucharest, Romania
| | - Claudia-Gabriela Potcovaru
- Doctoral School, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (D.P.); (H.P.); (O.A.C.)
- Rehabilitation Department 9, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- National Institute of Rehabilitation, Physical Medicine and Balneo-Climatology, 010024 Bucharest, Romania
| | - Horia Păunescu
- Doctoral School, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (D.P.); (H.P.); (O.A.C.)
- Rehabilitation Department 9, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Pharmacology and Pharmacotherapy, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- National Institute of Rehabilitation, Physical Medicine and Balneo-Climatology, 010024 Bucharest, Romania
| | - Oana Andreia Coman
- Doctoral School, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (D.P.); (H.P.); (O.A.C.)
- Department of Pharmacology and Pharmacotherapy, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
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Alashram AR, Janada Q, Ghrear T. Noninvasive brain stimulation for spasticity rehabilitation in multiple sclerosis: A systematic review of randomized controlled trials. PM R 2024; 16:268-277. [PMID: 37574913 DOI: 10.1002/pmrj.13055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 06/29/2023] [Accepted: 08/01/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE To investigate the effects of noninvasive brain stimulation (NIBS) on spasticity in people with multiple sclerosis (PwMS). LITERATURE SURVEY We searched PubMed, SCOPUS, MEDLINE, REHABDATA, PEDro, CINAHL, AMED, and Web of Science until December 2022. METHODOLOGY Studies were selected if they included PwMS, used transcranial direct current stimulation (tDCS) or repetitive transcranial magnetic stimulation (rTMS) as a main intervention, and were randomized controlled trials (RCTs) including at least one outcome measure evaluating spasticity. Two researchers individually screened the selected studies. The study's quality was assessed using the Cochrane Collaborations tool. The researchers decided that the meta-analysis was not possible because the treatment interventions varied among the selected studies. SYNTHESIS In total, 147 studies were reviewed. Of them, nine studies met the eligibility criteria and included 193 PwMS (mean age = 43.2 years), 54.4% of whom were female. Eight studies were considered "high" quality and one was considered "moderate" quality. Seven studies that used rTMS demonstrated a significant decrease in spasticity in PwMS after the intervention. The remaining studies that provided tDCS did not show meaningful effects. CONCLUSIONS The evidence for the influences of rTMS on spasticity in PwMS is promising. The evidence for the impact of tDCS on spasticity in PwMS was limited. Further RCTs with long-term follow-ups are encouraged.
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Affiliation(s)
- Anas R Alashram
- Department of Physiotherapy, Middle East University, Amman, Jordan
- Applied Science Research Center, Applied Science Private University, Amman, Jordan
| | - Qusai Janada
- Department of Physiotherapy, Middle East University, Amman, Jordan
| | - Tamara Ghrear
- Department of Physiotherapy, Middle East University, Amman, Jordan
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Malloy DC, Côté MP. Multi-session transcutaneous spinal cord stimulation prevents chloridehomeostasis imbalance and the development of spasticity after spinal cordinjury in rat. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.10.24.563419. [PMID: 37961233 PMCID: PMC10634766 DOI: 10.1101/2023.10.24.563419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Spasticity is a complex and multidimensional disorder that impacts nearly 75% of individuals with spinal cord injury (SCI) and currently lacks adequate treatment options. This sensorimotor condition is burdensome as hyperexcitability of reflex pathways result in exacerbated reflex responses, co-contractions of antagonistic muscles, and involuntary movements. Transcutaneous spinal cord stimulation (tSCS) has become a popular tool in the human SCI research field. The likeliness for this intervention to be successful as a noninvasive anti-spastic therapy after SCI is suggested by a mild and transitory improvement in spastic symptoms following a single stimulation session, but it remains to be determined if repeated tSCS over the course of weeks can produce more profound effects. Despite its popularity, the neuroplasticity induced by tSCS also remains widely unexplored, particularly due to the lack of suitable animal models to investigate this intervention. Thus, the basis of this work was to use tSCS over multiple sessions (multi-session tSCS) in a rat model to target spasticity after SCI and identify the long-term physiological improvements and anatomical neuroplasticity occurring in the spinal cord. Here, we show that multi-session tSCS in rats with an incomplete (severe T9 contusion) SCI (1) decreases hyperreflexia, (2) increases the low frequency-dependent modulation of the H-reflex, (3) prevents potassium-chloride cotransporter isoform 2 (KCC2) membrane downregulation in lumbar motoneurons, and (4) generally augments motor output, i.e., EMG amplitude in response to single pulses of tSCS, particularly in extensor muscles. Together, this work displays that multi-session tSCS can target and diminish spasticity after SCI as an alternative to pharmacological interventions and begins to highlight the underlying neuroplasticity contributing to its success in improving functional recovery.
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Affiliation(s)
- Dillon C. Malloy
- Marion Murray Spinal Cord Research Center, Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129
| | - Marie-Pascale Côté
- Marion Murray Spinal Cord Research Center, Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129
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6
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Verana G, Tijani AO, Puri A. Nanosuspension-based microneedle skin patch of baclofen for sustained management of multiple sclerosis-related spasticity. Int J Pharm 2023; 644:123352. [PMID: 37647979 DOI: 10.1016/j.ijpharm.2023.123352] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/25/2023] [Accepted: 08/26/2023] [Indexed: 09/01/2023]
Abstract
Baclofen (BAC) is the first-line recommendation to treat spasticity in people with multiple sclerosis whose treatment goals include improving mobility or easing pain. The short half-life of BAC calls for multiple daily dosing which may be eliminated by the development of a transdermal system. This study aimed to assess the effect of transdermal microneedle patches on improving the skin permeation of BAC. Nanosuspension-loaded microneedle patch containing BAC was fabricated and characterized. In vitro permeation of BAC across intact and microneedle-treated dermatomed porcine ear skin was evaluated. In vitro passive permeation of BAC solution after 72 h was observed to be 92.56 ± 11.24 µg/cm2. A near 9-fold enhancement was observed when employing the strategy of microneedle-mediated delivery of the solution. To increase drug loading, two strategies, nanosizing and microneedle-mediated delivery, were combined and permeation of BAC after 72 h resulted to be 1951.95 ± 82.01 µg/cm2 (p < 0.05). Microneedle-mediated transdermal delivery of BAC holds potential for sustained management of multiple sclerosis-related spasticity. Nanosizing of BAC particles facilitated higher drug loading in MN patches and an eventual increase in cumulative drug permeation from the patches.
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Affiliation(s)
- Gabrielle Verana
- Department of Pharmaceutical Sciences, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN 37614, United States
| | - Akeemat O Tijani
- Department of Pharmaceutical Sciences, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN 37614, United States
| | - Ashana Puri
- Department of Pharmaceutical Sciences, Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, TN 37614, United States.
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Gundersen BB, O'Brien WT, Schaffler MD, Schultz MN, Tsukahara T, Lorenzo SM, Nalesso V, Luo Clayton AH, Abel T, Crawley JN, Datta SR, Herault Y. Towards Preclinical Validation of Arbaclofen (R-baclofen) Treatment for 16p11.2 Deletion Syndrome. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.05.01.538987. [PMID: 37745360 PMCID: PMC10515778 DOI: 10.1101/2023.05.01.538987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
A microdeletion on human chromosome 16p11.2 is one of the most common copy number variants associated with autism spectrum disorder and other neurodevelopmental disabilities. Arbaclofen, a GABA(B) receptor agonist, is a component of racemic baclofen, which is FDA-approved for treating spasticity, and has been shown to alleviate behavioral phenotypes, including recognition memory deficits, in animal models of 16p11.2 deletion. Given the lack of reproducibility sometimes observed in mouse behavioral studies, we brought together a consortium of four laboratories to study the effects of arbaclofen on behavior in three different mouse lines with deletions in the mouse region syntenic to human 16p11.2 to test the robustness of these findings. Arbaclofen rescued cognitive deficits seen in two 16p11.2 deletion mouse lines in traditional recognition memory paradigms. Using an unsupervised machine-learning approach to analyze behavior, one lab found that arbaclofen also rescued differences in exploratory behavior in the open field in 16p11.2 deletion mice. Arbaclofen was not sedating and had modest off-target behavioral effects at the doses tested. Our studies show that arbaclofen consistently rescues behavioral phenotypes in 16p11.2 deletion mice, providing support for clinical trials of arbaclofen in humans with this deletion.
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Affiliation(s)
| | | | - Melanie D Schaffler
- MIND Institute, University of California Davis School of Medicine, Sacramento, CA
| | - Maria N Schultz
- MIND Institute, University of California Davis School of Medicine, Sacramento, CA
| | | | - Sandra Martin Lorenzo
- Université de Strasbourg, CNRS UMR7104, INSERM U1258, Institut de Genetique et de Biologie Moleculaire et Cellulaire (IGBMC), Illkirch cedex, France
| | - Valerie Nalesso
- Université de Strasbourg, CNRS UMR7104, INSERM U1258, Institut de Genetique et de Biologie Moleculaire et Cellulaire (IGBMC), Illkirch cedex, France
| | | | - Ted Abel
- University of Iowa, Iowa City, IA
| | - Jacqueline N Crawley
- MIND Institute, University of California Davis School of Medicine, Sacramento, CA
| | | | - Yann Herault
- Université de Strasbourg, CNRS UMR7104, INSERM U1258, Institut de Genetique et de Biologie Moleculaire et Cellulaire (IGBMC), Illkirch cedex, France
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Alharbi OA, Jarvis E, Galani A, Thomaidis NS, Nika MC, Chapman DV. Assessment of selected pharmaceuticals in Riyadh wastewater treatment plants, Saudi Arabia: Mass loadings, seasonal variations, removal efficiency and environmental risk. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 882:163284. [PMID: 37031940 DOI: 10.1016/j.scitotenv.2023.163284] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 06/01/2023]
Abstract
Despite increasing interest in pharmaceutical emissions worldwide, studies of environmental contamination with pharmaceuticals arising from wastewater discharges in Saudi Arabia are scarce. Therefore, this study examined occurrence, mass loads and removal efficiency for 15 pharmaceuticals and one metabolite (oxypurinol) from different therapeutic classes in three wastewater treatment plants (WWTPs), in Riyadh city in Saudi Arabia. A total of 144 samples were collected from the influents and effluents between March 2018 and July 2019 and analyzed using Solid Phase Extraction followed by triple quadrupole LC-MS/MS. The average concentrations in the influents and effluents were generally higher than their corresponding concentrations found either in previous Saudi Arabian or global studies. The four most dominant compounds in the influent were acetaminophen, ciprofloxacin, caffeine, and diclofenac, with caffeine and acetaminophen having the highest concentrations ranging between 943 and 2282 μg/L. Metformin and ciprofloxacin were the most frequently detected compounds in the effluents at concentrations as high as 33.2 μg/L. Ciprofloxacin had the highest mass load in the effluents of all three WWTPs, ranging between 0.20 and 20.7 mg/day/1000 inhabitants for different WWTPs. The overall average removal efficiency was estimated high (≥80), with no significant different (p > 0.05) between the treatment technology applied. Acetaminophen and caffeine were almost completely eliminated in all three WWTPs. The samples collected in the cold season generally had higher levels of detected compounds than those from the warm seasons, particularly for NSAID and antibiotic compounds. The estimated environmental risk from pharmaceutical compounds in the studied effluents was mostly low, except for antibiotic compounds. Thus, antibiotics should be considered for future monitoring programmes of the aquatic environment in Saudi Arabia.
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Affiliation(s)
- Obaid A Alharbi
- Water Management & Treatment Technologies Institute, Sustainability and Environment Sector, King Abdulaziz City for Science and Technology (KACST), Riyadh 12354, Saudi Arabia; School of Biological, Earth and Environmental Sciences, University College Cork, T23 N73K, Ireland.
| | - Edward Jarvis
- School of Biological, Earth and Environmental Sciences, University College Cork, T23 N73K, Ireland
| | - Aikaterini Galani
- Laboratory of Analytical Chemistry, Department of Chemistry, National and Kapodistrian University of Athens, University Campus, Zografou, 15771, Athens, Greece
| | - Nikolaos S Thomaidis
- Laboratory of Analytical Chemistry, Department of Chemistry, National and Kapodistrian University of Athens, University Campus, Zografou, 15771, Athens, Greece
| | - Maria-Christina Nika
- Laboratory of Analytical Chemistry, Department of Chemistry, National and Kapodistrian University of Athens, University Campus, Zografou, 15771, Athens, Greece
| | - Deborah V Chapman
- School of Biological, Earth and Environmental Sciences, University College Cork, T23 N73K, Ireland; Environmental Research Institute, University College Cork, T23 XE10, Ireland
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Hwang YJ, Chang AR, Brotman DJ, Inker LA, Grams ME, Shin JI. Baclofen and the Risk of Encephalopathy: A Real-World, Active-Comparator Cohort Study. Mayo Clin Proc 2023; 98:676-688. [PMID: 37028980 PMCID: PMC10159882 DOI: 10.1016/j.mayocp.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/10/2022] [Accepted: 11/03/2022] [Indexed: 04/09/2023]
Abstract
OBJECTIVE To quantify the risk of encephalopathy associated with oral baclofen compared with other muscle relaxants-tizanidine or cyclobenzaprine. PATIENTS AND METHODS We conducted a new-user, active-comparator study of 2 pairwise cohorts using tertiary health system data from Geisinger Health in Pennsylvania (January 1, 2005, through December 31, 2018). Adults (aged ≥18 years) newly treated with baclofen or tizanidine were included in cohort 1. Adults newly treated with baclofen or cyclobenzaprine were included in cohort 2. Propensity score-based inverse probability of treatment weighting (IPTW) was used to balance the respective cohorts on 45 patient characteristics. Fine-Gray competing risk regression was used to estimate the risk of encephalopathy. RESULTS Cohort 1 included 16,192 new baclofen users and 9782 new tizanidine users. The 30-day risk of encephalopathy was higher in patients treated with baclofen vs tizanidine (IPTW incidence rate, 64.7 vs 28.3 per 1000 person-years) with an IPTW subdistribution hazard ratio (SHR) of 2.29 (95% CI, 1.43 to 3.67). This risk persisted through 1 year (SHR, 1.32 [95% CI, 1.07 to 1.64]). Similarly in cohort 2, baclofen vs cyclobenzaprine was associated with a greater risk of encephalopathy at 30 days (SHR, 2.35 [95% CI, 1.59 to 3.48]) that persisted through the first year of treatment (SHR, 1.94 [95% CI, 1.56 to 2.40]). CONCLUSION The risk of encephalopathy was greater with baclofen vs tizanidine or cyclobenzaprine use. The elevated risk was apparent as early as 30 days and persisted through the first year of treatment. Our findings from routine care settings may inform shared treatment decisions between patients and prescribers.
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Affiliation(s)
- Y Joseph Hwang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD.
| | - Alex R Chang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Kidney Health Research Institute, Geisinger Health, Danville, PA
| | - Daniel J Brotman
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Morgan E Grams
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD; Departments of Medicine and Population Health, NYU Grossman School of Medicine, New York City, NY
| | - Jung-Im Shin
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD
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10
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Ito M, Walzer M, Blauwet MB, Spence A, Heo N, Kelsh D, Blahunka P, Erdman J, Alsharif MN, Marek GJ. A phase 1 randomized, placebo-controlled study to investigate potential interactions between ASP8062, a positive allosteric modulator of the GABA B receptor, and morphine in recreational opioid users. J Psychopharmacol 2023; 37:449-461. [PMID: 37125424 DOI: 10.1177/02698811231167852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
BACKGROUND Recent increases in opioid use and subsequent opioid use disorder are a major public health crisis in the United States. AIMS This phase 1 randomized, placebo-controlled study investigated the safety, tolerability, and pharmacokinetics (PKs) of ASP8062, a γ-aminobutyric acid B receptor-positive allosteric modulator, with and without administration of morphine in participants who used opioids recreationally. METHODS Participants were randomly assigned (2:1) to daily dosing with ASP8062 25 mg or placebo on days 1-10. On day 10, all participants received morphine as a single oral dose of 45 mg; assessments were performed on days 11-16. The primary end point was safety, evaluated as the nature, frequency, and severity of adverse events, and end-tidal CO2 levels. PK end points were a secondary outcome measure. RESULTS A total of 24 participants (aged 21-54 years) received ASP8062 (n = 16) or placebo (n = 8). There were no deaths or serious adverse events leading to treatment discontinuation during the study. Most adverse events were mild, with numerically lower absolute number of adverse events reported with ASP8062 plus morphine versus placebo plus morphine. ASP8062 plus morphine did not increase respiratory depression, potential drug abuse- or withdrawal-related adverse events. There were no significant PK interactions. CONCLUSIONS In this phase 1 study, we did not observe any unexpected safety signals or notable PK interactions with concomitant morphine administration. These data suggest a potentially low risk for an increase in drug abuse- or withdrawal-related adverse events or respiratory distress in participants exposed to ASP8062 and morphine.
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Affiliation(s)
- Mototsugu Ito
- Development Project Management, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Mark Walzer
- Clinical Pharmacology & Exploratory Development, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Mary Beth Blauwet
- Biostatistics Department, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Anna Spence
- Biostatistics Department, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Nakyo Heo
- Clinical Pharmacology & Exploratory Development, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Debra Kelsh
- Altasciences, Clinical Kansas, Inc., Overland Park, KS, USA
| | - Paul Blahunka
- Employee of Astellas, Northbrook, IL, USA, at the time of the study
| | - Jay Erdman
- Development Project Management, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Mohamad Nour Alsharif
- Development Project Management, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Gerard J Marek
- Employee of Astellas, Northbrook, IL, USA, at the time of the study
- Gilgamesh Pharmaceuticals Inc., New York, NY, USA
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11
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Akuzawa S, Irie M, Kanki M, Shirakawa T, Sato Y. Effect of ASP8062 on morphine self-administration and morphine-induced respiratory suppression in monkeys. J Pharmacol Sci 2023; 151:171-176. [PMID: 36925215 DOI: 10.1016/j.jphs.2023.02.003] [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: 08/23/2022] [Revised: 01/26/2023] [Accepted: 02/10/2023] [Indexed: 02/17/2023] Open
Abstract
ASP8062 is an orally available GABAB receptor positive allosteric modulator (PAM). This study assessed the potential of ASP8062 for treating opioid use disorder (OUD). Three rhesus monkeys were pretreated with ASP8062 (0.3, 1 or 3 mg/kg) by oral administration 1 h prior to a 2-h morphine self-administration session (0.03 mg/kg, iv, per injection) under a fixed-ratio 5 schedule. We further examined the potential worsening of morphine-induced respiratory suppression by ASP8062 after coadministration of morphine (10 mg/kg, sc) and ASP8062 (10 mg/kg, po) in cynomolgus monkeys using a custom-made whole-body plethysmograph. Plasma concentrations of ASP8062 (3 or 10 mg/kg, po) were assessed in cynomolgus monkeys using liquid chromatography-tandem mass spectroscopy (LC-MS/MS). ASP8062 at 3 mg/kg, po decreased the morphine self-administrations with significant differences from the vehicle-treated group (IC50 = 0.97 ± 0.36 mg/kg). Exposure levels at 3 mg/kg observed in monkeys were comparable to the clinical exposure levels which positive pharmacodynamic effects were previously shown. Further, ASP8062 did not potentiate morphine-induced respiratory suppression up to exposure levels higher than the clinically relevant dose. ASP8062 may reduce opioid use in OUD patients without affecting respiratory system, providing justification for further ASP8062 development as a potential treatment option for OUD.
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Affiliation(s)
- Shinobu Akuzawa
- Applied Pharmacology, Non-clinical Regulatory Science, Applied Research, Astellas Pharma Inc., 21 Miyukigaoka, Tsukuba, Ibaraki, 305-8585, Japan.
| | - Megumi Irie
- Applied Drug Metabolism & Pharmacokinetics, Non-clinical Regulatory Science, Applied Research, Astellas Pharma Inc., 21 Miyukigaoka, Tsukuba, Ibaraki, 305-8585, Japan
| | - Masayuki Kanki
- Applied Safety, Non-clinical Regulatory Science, Applied Research, Astellas Pharma Inc., 21 Miyukigaoka, Tsukuba, Ibaraki, 305-8585, Japan
| | - Takafumi Shirakawa
- Applied Safety, Non-clinical Regulatory Science, Applied Research, Astellas Pharma Inc., 21 Miyukigaoka, Tsukuba, Ibaraki, 305-8585, Japan
| | - Yuichiro Sato
- Research Program Management, Applied Research Management, Applied Research, Astellas Pharma Inc., 21 Miyukigaoka, Tsukuba, Ibaraki, 305-8585, Japan
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12
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Ito M, Walzer M, Beth Blauwet M, Spence A, Heo N, Kelsh D, Blahunka P, Erdman J, Nour Alsharif M, Marek GJ. A phase 1b study to investigate the potential interactions between ASP8062 and buprenorphine/naloxone in patients with opioid use disorder. J Psychopharmacol 2023; 37:144-154. [PMID: 36738100 DOI: 10.1177/02698811221149657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND There is an unmet need for therapeutics with greater efficacy and tolerability for the treatment of opioid use disorder (OUD). ASP8062 is a novel compound with positive allosteric modulator activity on the γ-aminobutyric acid type B receptor under development for use with standard-of-care treatment for patients with OUD. AIMS To investigate the safety, tolerability, interaction potential, and pharmacokinetics (PK) of ASP8062 in combination with buprenorphine/naloxone (B/N; Suboxone®). METHODS In this phase 1, randomized, double-masked, placebo-controlled study, patients with OUD began B/N (titrated to 16/4 mg/day) treatment upon enrollment (induction, Days 1-4; maintenance, Days 5-18; downward titration, Days 19-26; and discharge, Day 27). On Day 12, patients received a single dose of ASP8062 60 mg or placebo with B/N and underwent safety and PK assessments. Primary endpoints included frequency and severity of treatment-emergent adverse events (TEAEs), clinical laboratory tests, respiratory depression, and suicidal ideation. Secondary endpoints investigated the impact of ASP8062 on B/N PK. RESULTS Eighteen patients were randomized and completed the study (ASP8062, n = 12; placebo, n = 6). With this sample size typical for phase 1 drug-drug interaction studies, ASP8062 was well tolerated; most TEAEs were mild in severity, and none led to treatment withdrawal. ASP8062 did not enhance substance use-related TEAEs, respiratory depression, or suicidal ideation and did not have a clinically significant impact on the PK of B/N. CONCLUSIONS In this phase 1 study, ASP8062 was safe, well tolerated, and did not enhance respiratory suppression induced by buprenorphine. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT04447287.
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Affiliation(s)
- Mototsugu Ito
- Development Project Management, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Mark Walzer
- Clinical Pharmacology and Exploratory Development, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Mary Beth Blauwet
- Biostatistics Department, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Anna Spence
- Biostatistics Department, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Nakyo Heo
- Clinical Pharmacology and Exploratory Development, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | - Debra Kelsh
- Altasciences Clinical Kansas, Inc., Overland Park, KS, USA
| | | | - Jay Erdman
- Medical Specialties, Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | | | - Gerard J Marek
- Employee of Astellas at the time of the study.,Gilgamesh Pharmaceuticals, Inc., New York, NY, USA
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Reinert JP, Kormanyos Z. Pharmacologic Management of Central Fever: A Review of Evidence for Bromocriptine, Propranolol, and Baclofen. J Pharm Technol 2023; 39:29-34. [PMID: 36755757 PMCID: PMC9899958 DOI: 10.1177/87551225221132678] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective: The purpose of this review was to evaluate the clinical data supporting bromocriptine, propranolol, and baclofen in the pharmacologic management of central fever. Data Sources: A comprehensive literature review was performed between January 2018 and August 2022 using the following keywords: "central fever" NOT "fever" OR "infection" OR "infectious" AND "neurocritical" OR "neurology" AND "treatment" AND "medication" OR "medicine" OR "drug" OR "pharmaceutical." Study Selection and Data Extraction: A total of 6 case reports met specified inclusion criteria, with 2 reporting on each of the evaluated medications. Data Synthesis: Significant heterogeneity exists regarding dosing strategies and duration of treatment with these medications for the management of central fever. Although each medication demonstrated the ability to restore normothermia, the variation in underlying cause of the fever and lack of cross-over evaluation between different medications makes a definitive treatment strategy for any of these agents elusive. Conclusions: The development of a central fever has been associated with poor outcomes in patients who have suffered a critical neurologic injury. Although their exact mechanism for this indication has not been fully elucidated, anecdotal evidence seemingly supports the use of bromocriptine, propranolol, and baclofen.
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Affiliation(s)
- Justin P. Reinert
- Clinical Pharmacy, College of Pharmacy
and Pharmaceutical Sciences, The University of Toledo, Toledo, OH, USA
| | - Zsanett Kormanyos
- Department of Pharmaceutical Care,
Mercy Health St. Vincent Medical Center, Toledo, OH, USA
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Cotinat M, Boquet I, Ursino M, Brocard C, Jouve E, Alberti C, Bensoussan L, Viton JM, Brocard F, Blin O. Riluzole for treating spasticity in patients with chronic traumatic spinal cord injury: Study protocol in the phase ib/iib adaptive multicenter randomized controlled RILUSCI trial. PLoS One 2023; 18:e0276892. [PMID: 36662869 PMCID: PMC9858801 DOI: 10.1371/journal.pone.0276892] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 10/15/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Satisfactory treatment is often lacking for spasticity, a highly prevalent motor disorder in patients with spinal cord injury (SCI). Low concentrations of riluzole potently reduce the persistent sodium current, the post-SCI increase in which contributes to spasticity. The repurposing of this drug may therefore constitute a useful potential therapeutic option for relieving SCI patients suffering from chronic traumatic spasticity. OBJECTIVE RILUSCI is a phase 1b-2b trial designed to assess whether riluzole is a safe and biologically effective means of managing spasticity in adult patients with traumatic chronic SCI. METHODS In this multicenter double-blind trial, adults (aged 18-65 years) suffering from spasticity after SCI (target enrollment: 90 participants) will be randomly assigned to be given either a placebo or a recommended daily oral dose of riluzole for two weeks. The latter dose will be previously determined in phase 1b of the study by performing double-blind dose-finding tests using a Bayesian continuous reassessment method. The primary endpoint of the trial will be an improvement in the Modified Ashworth Score (MAS) or the Numerical Rating Score (NRS) quantifying spasticity. The secondary outcomes will be based on the safety and pharmacokinetics of riluzole as well as its impact on muscle spasms, pain, bladder dysfunction and quality of life. Analyses will be performed before, during and after the treatment and the placebo-controlled period. CONCLUSION To the best of our knowledge, this clinical trial will be the first to document the safety and efficacy of riluzole as a means of reducing spasticity in patients with chronic SCI. TRIAL REGISTRATION The clinical trial, which is already in progress, was registered on the ClinicalTrials.gov website on August 9, 2016 under the registration number NCT02859792. TRIAL SPONSOR Assistance Publique-Hôpitaux de Marseille.
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Affiliation(s)
- Maëva Cotinat
- Institut de Neurosciences de la Timone (UMR7289), Aix-Marseille Université and CNRS, Marseille, France
- Department of Physical and Rehabilitation Medicine, Sainte Marguerite University Hospital, APHM, Marseille, France
| | - Isabelle Boquet
- Institut de Neurosciences de la Timone (UMR7289), Aix-Marseille Université and CNRS, Marseille, France
| | - Moreno Ursino
- Unit of Clinical Epidemiology, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Robert Debré, FCRIN PARTNERS Platform, Université de Paris, Sorbonne Paris-Cité, INSERM U1123 and CIC-EC 1426, Paris, France
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, USPC, Université de Paris, F-75006 Paris, France
- Inria, Paris, France
| | - Cécile Brocard
- Institut de Neurosciences de la Timone (UMR7289), Aix-Marseille Université and CNRS, Marseille, France
| | - Elisabeth Jouve
- Aix Marseille University, APHM, INSERM, Inst Neurosci Syst, UMR1106, Service de Pharmacologie Clinique et Pharmacovigilance, Marseille, France
| | - Corinne Alberti
- Unit of Clinical Epidemiology, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Robert Debré, FCRIN PARTNERS Platform, Université de Paris, Sorbonne Paris-Cité, INSERM U1123 and CIC-EC 1426, Paris, France
| | - Laurent Bensoussan
- Institut de Neurosciences de la Timone (UMR7289), Aix-Marseille Université and CNRS, Marseille, France
- Institut Universitaire de Réadaptation de Valmante Sud, UGECAM, Marseille, France
| | - Jean-Michel Viton
- Institut de Neurosciences de la Timone (UMR7289), Aix-Marseille Université and CNRS, Marseille, France
- Department of Physical and Rehabilitation Medicine, Sainte Marguerite University Hospital, APHM, Marseille, France
| | - Frédéric Brocard
- Institut de Neurosciences de la Timone (UMR7289), Aix-Marseille Université and CNRS, Marseille, France
| | - Olivier Blin
- Aix Marseille University, APHM, INSERM, Inst Neurosci Syst, UMR1106, Service de Pharmacologie Clinique et Pharmacovigilance, Marseille, France
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15
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Agabio R, Saulle R, Rösner S, Minozzi S. Baclofen for alcohol use disorder. Cochrane Database Syst Rev 2023; 1:CD012557. [PMID: 36637087 PMCID: PMC9837849 DOI: 10.1002/14651858.cd012557.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Alcohol use disorder (AUD) is one of the most widespread psychiatric disorders leading to detrimental consequences to people with this disorder and others. Worldwide, the prevalence of heavy episodic drinking (30-day prevalence of at least one occasion of 60 g of pure alcohol intake among current drinkers) is estimated at 20% and the prevalence of AUD at 5% of the adult general population, with highest prevalence in Europe and North America. Therapeutic approaches, including pharmacotherapy, play an important role in treating people with AUD. This is an update of a Cochrane Review first published in 2018. OBJECTIVES To evaluate the benefits and harms of baclofen on achieving and maintaining abstinence or reducing alcohol consumption in people with AUD compared to placebo, no treatment or any other pharmacological relapse prevention treatment. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search was 22 November 2021. SELECTION CRITERIA Randomised controlled trials (RCTs) of at least four weeks' treatment duration and 12 weeks' overall study duration comparing baclofen for AUD treatment with placebo, no treatment or other treatments. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. relapse, 2. frequency of use, 3. amount of use, 4. adverse events, 5. dropouts from treatment and 6. dropouts from treatment due to adverse events. Our secondary outcomes were 7. craving, 8. anxiety, 9. depression and 10. frequency of most relevant adverse events. MAIN RESULTS We included 17 RCTs (1818 participants) with a diagnosis of alcohol dependence according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition or International Classification of Diseases 10th edition criteria. Mean age was 46.5 years and 70% were men. Ten studies compared baclofen to placebo or another medication; seven compared two baclofen doses to placebo or another medication. Globally, 15 studies compared baclofen to placebo, two baclofen to acamprosate and two baclofen to naltrexone. In 16 studies, participants received psychosocial treatments. We judged most studies at low risk of selection, performance, detection (subjective outcome), attrition and reporting bias. Ten studies detoxified participants before treatment; in seven studies, participants were still drinking at the beginning of treatment. Treatment duration was 12 weeks for 15 RCTs and longer in two studies. Baclofen daily dose was 30 mg to 300 mg: 10 RCTs used low doses (30 mg or less); eight RCTs medium doses (above 30 and 100 mg or less) and four RCTs high doses (above 100 mg). Compared to placebo, moderate-certainty evidence found that baclofen probably decreases the risk to relapse (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.77 to 0.99; 12 studies, 1057 participants). This result was confirmed among detoxified participants but not among other subgroups of participants. High-certainty evidence found that baclofen increases the percentage of days abstinent (mean difference (MD) 9.07, 95% CI 3.30 to 14.85; 16 studies, 1273 participants). This result was confirmed among all subgroups of participants except non-detoxified or those who received medium doses. There was no difference between baclofen and placebo in the other primary outcomes: heavy drinking days (standardised mean difference (SMD) -0.18, 95% CI -0.48 to 0.11; 13 studies, 840 participants; moderate-certainty evidence); number of drinks per drinking days (MD -0.45, 95% CI -1.20 to 0.30; 9 studies, 392 participants; moderate-certainty evidence); number of participants with at least one adverse event (RR 1.05, 95% CI 0.99 to 1.11; 10 studies, 738 participants; high-certainty evidence); dropouts (RR 0.88, 95% CI 0.74 to 1.03; 17 studies, 1563 participants; high-certainty evidence); dropouts due to adverse events (RR 1.39, 95% CI 0.89 to 2.18; 16 studies, 1499 participants; high-certainty evidence). These results were confirmed by subgroup analyses except than for the dropouts that resulted lower among participants who received high doses of baclofen and studies longer than 12 weeks. Compared to placebo, there was no difference in craving (SMD -0.16, 95% CI -0.37 to 0.04; 17 studies, 1275 participants), anxiety (MD -0.01, 95% CI -0.14 to 0.11; 15 studies, 1123 participants) and depression (SMD 0.07, 95% CI -0.12 to 0.27; 11 studies, 1029 participants). Concerning the specific adverse events, baclofen increases fatigue, dizziness, somnolence/sedation, dry mouth, paraesthesia and muscle spasms/rigidity. There was no difference in the other adverse events. Compared to acamprosate, one study (60 participants) found no differences in any outcomes but the evidence was very uncertain: relapse (RR 1.25, 95% CI 0.71 to 2.20; very low-certainty evidence); number of participants with at least one adverse event (RR 0.63, 95% CI 0.23 to 1.69; very low-certainty evidence); dropouts (RR 0.56, 95% CI 0.21 to 1.46; very low-certainty evidence); dropouts due to adverse events (RR 0.33, 95% CI 0.01 to 7.87; very low-certainty evidence) and craving (MD 5.80, 95% CI -11.84 to 23.44); and all the adverse events evaluated. Compared to naltrexone, baclofen may increase the risk of relapse (RR 2.50, 95% CI 1.12 to 5.56; 1 study, 60 participants; very low-certainty evidence) and decrease the number of participants with at least one adverse event (RR 0.35, 95% CI 0.15 to 0.80; 2 studies, 80 participants; very low-certainty evidence) but the evidence is very uncertain. One study (60 participants) found no difference between baclofen and naltrexone in the dropouts at the end of treatment (RR 1.00, 95% CI 0.32 to 3.10; very low-certainty evidence), craving (MD 2.08, 95% CI -3.71 to 7.87), and all the adverse events evaluated. AUTHORS' CONCLUSIONS Baclofen likely reduces the risk of relapse to any drinking and increases the percentage of abstinent days, mainly among detoxified participants. It does not increase the number of participants with at least one adverse event, those who dropout for any reason or due to adverse events. It probably does not reduce number of heavy drinking days and the number of drinks per drinking days. Current evidence suggests that baclofen may help people with AUD in maintaining abstinence. The results of comparisons of baclofen with acamprosate and naltrexone were mainly based on only one study.
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Affiliation(s)
- Roberta Agabio
- Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Monserrato (CA), Italy
| | - Rosella Saulle
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | | | - Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
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Intrathecal Baclofen for Spasticity: Is There an Effect on Bladder Function? Report of Three Cases and Review of the Literature. Biomedicines 2022; 10:biomedicines10123266. [PMID: 36552022 PMCID: PMC9775073 DOI: 10.3390/biomedicines10123266] [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: 11/15/2022] [Revised: 12/07/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION traumatic brain injury (TBI) is very often associated with spasticity. Medical interventions may include medications such as baclofen, a Gamma-Aminobutyric Acid (GABA) -receptor agonist of poor lipid solubility. Intrathecal baclofen (ITB) administration is a contemporary treatment option which minimizes adverse effects in contrast with the oral form of the drug. Regarding low urinary tract dysfunction, TBI, as a suprapontine lesion, results in neurogenic detrusor overactivity. Frequency, urgency and urge incontinence are the predominant signs and symptoms of this condition. Our study aims to report the potential changes in bladder function in patients with spasticity, due to TBI, after the implantation of the baclofen pump and the control of spasticity. MATERIAL AND METHODS We report three cases of TBI whose spasticity responded well to ITB. We evaluated our medical reports regarding bladder function retrospectively, before and after baclofen pump implantation. We compared the data of bladder diaries and urodynamic parameters. RESULTS Bladder function was improved in all patients. Regarding bladder diaries; the number of incontinence and micturition episodes was decreased and the volume per void was slightly increased. Regarding urodynamic parameters; bladder capacity and reflex volume increased, Pdetmax decreased, PVR was the same and DLPP was slightly decreased. CONCLUSIONS Although the baclofen pump is implanted to treat spasticity, detrusor activity may be also affected. Therefore, patients' urologic profiles should also be reevaluated after ITB. Further prospective studies are required to investigate the effect of ITB on bladder function in the clinical field and also at the basic science level.
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17
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Fischler PV, Soyka M, Seifritz E, Mutschler J. Off-label and investigational drugs in the treatment of alcohol use disorder: A critical review. Front Pharmacol 2022; 13:927703. [PMID: 36263121 PMCID: PMC9574013 DOI: 10.3389/fphar.2022.927703] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
Compounds known to be successful in the treatment of alcohol use disorder include the aversive agent, Disulfiram, the glutamatergic NMDA receptor antagonist, Acamprosate, and the opioid receptor antagonists, Naltrexone and Nalmefene. Although all four are effective in maintaining abstinence or reduction of alcohol consumption, only a small percentage of patients receive pharmacological treatment. In addition, many other medications have been investigated for their therapeutic potential in the treatment of alcohol use disorder. In this review we summarize and compare Baclofen, Gabapentin, Topiramate, Ondansetron, Varenicline, Aripiprazole, Quetiapine, Clozapine, Antidepressants, Lithium, Neuropeptide Y, Neuropeptide S, Corticotropin-releasing factor antagonists, Oxytocin, PF-05190457, Memantine, Ifenprodil, Samidorphan, Ondelopran, ABT-436, SSR149415, Mifepristone, Ibudilast, Citicoline, Rimonabant, Surinabant, AM4113 and Gamma-hydroxybutyrate While some have shown promising results in the treatment of alcohol use disorder, others have disappointed and should be excluded from further investigation. Here we discuss the most promising results and highlight medications that deserve further preclinical or clinical study. Effective, patient-tailored treatment will require greater understanding provided by many more preclinical and clinical studies.
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Affiliation(s)
- Pascal Valentin Fischler
- Department for Gynecology and Obstetrics, Women’s Clinic Lucerne, Cantonal Hospital of Lucerne, Lucerne, Switzerland
- *Correspondence: Pascal Valentin Fischler,
| | - Michael Soyka
- Psychiatric Hospital University of Munich, Munich, Germany
| | - Erich Seifritz
- Director of the Clinic for Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Clinic Zürich, Zürich, Switzerland
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18
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Gündüz HB. Results of Intrathecal Baclofen Treatment in Sixteen Spasticity Patients According to Four Different Measurement Scales: A Retrospective Analysis. Cureus 2022; 14:e26980. [PMID: 35989772 PMCID: PMC9385166 DOI: 10.7759/cureus.26980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes. It occurs as a result of overstimulation of the stretch reflex and is a component of the upper motor neuron syndrome. Intrathecal Baclofen (ITB) pump administration in patients with a diagnosis of spasticity may be a suitable option for reducing the complaints of the patients and increasing their quality of life. The aim of this study is to analyze clinically and statistically the diagnosis, treatment criteria, and post-treatment results of patients with spasticity who were treated in our clinic. Materials and Method Sixteen patients who were diagnosed with spasticity and placed on an intrathecal Baclofen pump between January 2015 and December 2020 were included in this study. An intrathecal Baclofen trial was first applied to patients who were candidates for the Baclofen pump. The spasticity levels of the patients who decided to have an intrathecal Baclofen pump were scored according to the modified Ashworth scale (MAS) and Penn spasm frequency scale (PSFS). In addition, the scaling of the patients' own conditions according to the visual analogue scale (VAS) and ambulation status according to the modified functional ambulation classification (MFAC) were recorded. All these evaluations were repeated in the preoperative, early postoperative, and follow-up periods. Results The sex distribution of the patients included in the study was equal to eight women and eight men. The age distribution was between 18 and 76. The average age was 40.62 (standard deviation ±17.79). The average preoperative modified Ashworth scale score was 3.73, and the average Penn spasm frequency scale score of the patients was 3.67. The average preoperative modified functional ambulation classification score was 1.87, and the average visual analogue scale score was 6.67. At the end of the second postoperative week, the average modified Ashworth scale score was 1.80 and the average Penn spasm frequency scale score was 1.67. The modified functional ambulation classification score was 2.60 and the visual analogue scale score was 4.58. The average follow-up period of the patients was 64 months. At the end of the follow-up periods, the average late-period modified Ashworth scale score was 1.87, and the Penn spasm frequency scale score was 1.67. The average modified functional ambulation classification score was 3.00, and the average visual analogue scale score was 4.50. Statistically, there was a significant difference between preoperative and postoperative results in both modified Ashworth scale and Penn spasm frequency scale scores (P<0.05). Modified functional ambulation classification preoperative and postoperative comparison results (P<0.05) and visual analogue scale results (P<0.05) were also statistically significant. No significant difference was found between the early postoperative period and the late postoperative period in all measurements (P=1.00). Conclusion Intrathecal Baclofen administration is one of the many treatment options for spasticity. In this way, it has been shown that greater Baclofen efficacy is achieved and its side effects are reduced. It should always be remembered that the process of this treatment is teamwork that requires the participation of more than one specialty branch. Physical therapists, neurologists, pediatricians, and neurosurgeons should be included in this teamwork.
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Maliha M, Roksana Z, Dutta P, Mamoon MY, Islam MQ. A Case Report of Baclofen- and Clozapine-Induced Dyskinesia: A Movement Disorder. Cureus 2022; 14:e25068. [PMID: 35719768 PMCID: PMC9203264 DOI: 10.7759/cureus.25068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2022] [Indexed: 11/28/2022] Open
Abstract
Movement disorder is a broad term comprising multiple disorders which result in either an excess or a paucity of voluntary and involuntary movements. There are numerous pieces of literature on drug-induced dyskinesia, although the exact mechanism underlying this phenomenon is yet to be understood. Drug-induced movement disorder is a complex and often neglected clinical presentation. There are various interactions of drugs with the dopaminergic, GABAergic, and serotonergic pathways in the body that seem to be the foundation, leading to these movement disorders. Further research and clinical trials are required to understand this clinical entity.
Here we present a case report of GABAergic baclofen and an anti-dopaminergic clozapine-induced atypical case of dyskinesia, a severe form of movement disorder in a 69-year-old-male with a past medical history of physiologic tremor and neuropathic pain.
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Štětkářová I, Keller J. Modulation of Motor Cortex Activity After Intrathecal Baclofen Delivery in Chronic Thoracic Spinal Cord Injury. Front Neurol 2022; 13:778697. [PMID: 35645987 PMCID: PMC9136289 DOI: 10.3389/fneur.2022.778697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesIntrathecal baclofen (ITB) is commonly used for reduction of spasticity in chronic spinal cord injury (SCI). Its clinical effect is well-known; however, exact mechanisms of long-term effect of continuous ITB administration (cITBa) on modulation of cortical processes have not been elucidated. The aim of this study was to evaluate changes in motor cortex activation for healthy upper limbs in comparison to impaired lower limbs by functional magnetic resonance imaging (fMRI).MethodsTen subjects (eight males, 20–69 years) with thoracic SCI presenting no voluntary movements of lower limbs (except one) were enrolled in the fMRI study. fMRI at 1.5T with a finger tapping paradigm and mental movement simulating foot flexion on the dominant side were performed before, 3 months, and 1 year after start of cITBa. fMRI data processing was carried out using FMRI Expert Analysis Tool (FEAT), part of FSL. A second-level analysis was carried out using FLAME stages 1 and 2. The level of spasticity was assessed with the Modified Ashworth scale (MAS).ResultsContinuous ITB significantly decreased limb spasticity in all the subjects (group MAS spasticity dropped from 3 to 0.3). The second-level analysis (Z > 1.6, cluster significance threshold p =0.05) revealed increased activation of the primary sensorimotor cortex of the foot between baseline and 3 months, and 3 months and 1 year.ConclusionIncreased sensorimotor cortex activation with spasticity reduction after cITBa may reflect distant functional reorganization because of long-term mediated neuroplastic changes in the sensorimotor cortex. Better understanding of modulation of brain function in SCI after cITBa may influence the field of neurorehabilitation.
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Affiliation(s)
- Ivana Štětkářová
- Department of Neurology, Third Faculty of Medicine, Královské Vinohrady University Hospital, Prague, Czechia
- *Correspondence: Ivana Štětkářová
| | - Jiří Keller
- Department of Neurology, Third Faculty of Medicine, Královské Vinohrady University Hospital, Prague, Czechia
- Department of Radiology, Na Homolce Hospital, Prague, Czechia
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21
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Samineni AV, Eklund SE, Miller PE, Buxton K, Snyder BD, Matheney TH, Watkins CJ, Stone SSD, Alrayashi W, Brusseau R, Shore BJ. Epidural Analgesia Versus Lumbar Plexus Blockade After Hip Reconstruction Surgery in Children With Cerebral Palsy and Intrathecal Baclofen Pumps: A Comparison of Safety and Efficacy. J Pediatr Orthop 2022; 42:222-228. [PMID: 35051954 DOI: 10.1097/bpo.0000000000002056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Epidural analgesia is commonly used for pain control after reconstructive hip surgery, but its use is controversial in the presence of an intrathecal baclofen pump (ITB). The purpose of this retrospective study was to investigate the rate of serious anesthetic and postoperative complications as well as the efficacy of epidural analgesia compared with lumbar plexus blocks (LPBs) for pain management after neuromuscular hip reconstruction in children with cerebral palsy (CP) and ITB. METHODS Pediatric patients with CP and ITB undergoing hip reconstructive surgery from 2010 to 2019 were retrospectively identified. Patients receiving epidural analgesia were compared with those receiving LPB. Morphine milligram equivalents per kilogram were used as a surrogate measure for pain-related outcomes, as pain scores were reported with wide ranges (eg, 0 to 5/10), making it unfeasible to compare them across the cohort. Postoperative complications were graded using the modified Clavien-Dindo classification. RESULTS Forty-four patients (26/44, 59% male) underwent surgery at an average age of 10.3 years (SD=3.4 y, range: 4 to 17 y). The majority utilized LPB (28/44, 64%) while the remaining utilized epidural (16/44, 36%). There were no differences in rates of serious complications, including no cases of ITB malfunction, damage, or infection. During the immediate postoperative course, patients who received LPB had higher morphine milligram equivalents per kilogram requirements than patients who received epidural analgesia. CONCLUSIONS In patients with CP undergoing hip reconstruction surgery with an ITB in situ, epidural anesthesia was associated with improved analgesia compared with LPB analgesia, with a similar risk for adverse outcomes. Epidural catheters placed using image-guided insertion techniques can avoid damage to the ITB catheter while providing effective postoperative pain control without increasing rates of complications in this complex patient population. LEVEL OF EVIDENCE Level III.
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22
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Blomqvist KJ, Skogster MOB, Kurkela MJ, Rosenholm MP, Ahlström FHG, Airavaara MT, Backman JT, Rauhala PV, Kalso EA, Lilius TO. Systemic hypertonic saline enhances glymphatic spinal cord delivery of lumbar intrathecal morphine. J Control Release 2022; 344:214-224. [PMID: 35301056 DOI: 10.1016/j.jconrel.2022.03.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 12/13/2022]
Abstract
The blood-brain barrier significantly limits effective drug delivery to central nervous system (CNS) targets. The recently characterized glymphatic system offers a perivascular highway for intrathecally (i.t.) administered drugs to reach deep brain structures. Although periarterial cerebrospinal fluid (CSF) influx and concomitant brain drug delivery can be enhanced by pharmacological or hyperosmotic interventions, their effects on drug delivery to the spinal cord, an important target for many drugs, have not been addressed. Hence, we studied in rats whether enhancement of periarterial flow by systemic hypertonic solution might be utilized to enhance spinal delivery and efficacy of i.t. morphine. We also studied whether the hyperosmolar intervention affects brain or cerebrospinal fluid drug concentrations after systemic administration. Periarterial CSF influx was enhanced by intraperitoneal injection of hypertonic saline (HTS, 5.8%, 20 ml/kg, 40 mOsm/kg). The antinociceptive effects of morphine were characterized, using tail flick, hot plate and paw pressure tests. Drug concentrations in serum, tissue and microdialysis samples were determined by liquid chromatography-tandem mass spectrometry. Compared with isotonic solution, HTS increased concentrations of spinal i.t. administered morphine by 240% at the administration level (T13-L1) at 60 min and increased the antinociceptive effect of morphine in tail flick, hot plate, and paw pressure tests. HTS also independently increased hot plate and paw pressure latencies but had no effect in the tail flick test. HTS transiently increased the penetration of intravenous morphine into the lateral ventricle, but not into the hippocampus. In conclusion, acute systemic hyperosmolality is a promising intervention for enhanced spinal delivery of i.t. administered morphine. The relevance of this intervention should be expanded to other i.t. drugs and brought to clinical trials.
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Affiliation(s)
- Kim J Blomqvist
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland.
| | - Moritz O B Skogster
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Mika J Kurkela
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Department of Clinical Pharmacology, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marko P Rosenholm
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Center for Translational Neuromedicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Fredrik H G Ahlström
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Mikko T Airavaara
- Faculty of Pharmacy and Neuroscience Center, University of Helsinki, Helsinki, Finland
| | - Janne T Backman
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Department of Clinical Pharmacology, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pekka V Rauhala
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Eija A Kalso
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Finland; SleepWell Research Programme, Faculty of Medicine, University of Helsinki, Finland
| | - Tuomas O Lilius
- Department of Pharmacology, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Center for Translational Neuromedicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Junaid MSA, Banga AK. Transdermal Delivery of Baclofen Using Iontophoresis and Microneedles. AAPS PharmSciTech 2022; 23:84. [PMID: 35288825 DOI: 10.1208/s12249-022-02232-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/01/2022] [Indexed: 11/30/2022] Open
Abstract
Baclofen, a GABAb agonist, is used in the treatment of multiple sclerosis, a neurodegenerative disease. Currently available dosage forms to deliver baclofen are through the oral and the intrathecal routes. The disadvantage of oral baclofen is that it requires administering the drug multiple times a day, owing to baclofen's short half-life. On the other hand, intrathecal baclofen pumps are invasive and cannot be an alternative to oral baclofen. Hence, there is a need to develop a dosage form that can deliver baclofen non-invasively and for an extended period at a steady rate, increasing the dosing interval. A transdermal baclofen delivery system might be the solution to this problem. Hence, this research focuses on evaluating microneedles, iontophoresis, and a combination of microneedles-iontophoresis as transdermal delivery enhancement strategies for baclofen. In vitro permeation studies were conducted on dermatomed porcine ear skin using vertical Franz diffusion cells to evaluate transdermal baclofen delivery. Anodal iontophoresis was applied at a current density of 0.5 mA/cm2, and transdermal delivery was assessed from pH 4.5 (45.51±0.76 μg/cm2) and pH 7.4 (68.84±10.13 μg/cm2) baclofen solutions. Iontophoresis enhanced baclofen delivery but failed to reach target delivery. Maltose microneedles were used to create hydrophilic microchannels on the skin, and this technique enhanced baclofen delivery by 89-fold. Both microneedles (447.88±68.06 μg/cm2) and combination of microneedles - iontophoresis (428.56±84.33 μg/cm2) reached the target delivery range (222-1184 μg/cm2) for baclofen. The findings of this research suggest that skin could be a viable route for delivery of baclofen. Graphical Abstract.
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Qin ES, Patel H, Montagnino J, Pham K, Lam NY. Behavioral dysregulation exacerbated by intrathecal baclofen in an adolescent with severe traumatic brain injury. J Pediatr Rehabil Med 2022; 15:383-387. [PMID: 35466913 DOI: 10.3233/prm-210018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This is a case of a 19-year-old male with a history of remote severe traumatic brain injury (TBI) with an intrathecal baclofen (ITB) pump for dystonia management. Given concern for lack of efficacy despite increasing doses of ITB, his catheter was evaluated and found to be epidural rather than intrathecal. The baclofen dose was down-titrated and he underwent catheter revision. Post-op, his baclofen dose was up-titrated and complicated by significant behavioral changes including aggressive physical and verbal behaviors resulting in hospitalization. Work-up was negative for infection, new neurologic pathology, and epileptic activity. Psychiatric medications were adjusted but the behaviors persisted. Due to concern that the increased baclofen dose was causing his mood instability, his pump was down-titrated. As the dosage decreased, the frequency of outbursts also decreased. Throughout these dose adjustments, his dystonia remained stable and overall functional status improved. This is one of the first cases demonstrating that ITB may exacerbate mood instability in patients with TBI.
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Affiliation(s)
- Evelyn S Qin
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Hetal Patel
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Jami Montagnino
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Kelly Pham
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Ny-Ying Lam
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
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25
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Belov F, Villinger A, von Langermann J. ( R)-Baclofen [( R)-4-amino-3-(4-chloro-phen-yl)butanoic acid]. Acta Crystallogr E Crystallogr Commun 2022; 78:33-35. [PMID: 35079419 PMCID: PMC8739196 DOI: 10.1107/s2056989021012809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/01/2021] [Indexed: 11/28/2022]
Abstract
This article provides the first single-crystal XRD-based structure of enanti-opure (R)-baclofen (form C), C10H12ClNO2, without any co-crystallized substances. In the enanti-opure title compound, the mol-ecules arrange themselves in an ortho-rhom-bic crystal structure (space group P212121). In the crystal, strong hydrogen bonds and C-H⋯Cl bonds inter-connect the zwitterionic mol-ecules.
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Affiliation(s)
- Feodor Belov
- University of Rostock, Institute of Chemistry, Biocatalytic synthesis group, Albert-Einstein-Str. 3A, 18059 Rostock, Germany
| | - Alexander Villinger
- University of Rostock, Institute of Chemistry, X-ray structure analytics, Albert-Einstein-Str. 3A, 18059 Rostock, Germany
| | - Jan von Langermann
- University of Rostock, Institute of Chemistry, Biocatalytic synthesis group, Albert-Einstein-Str. 3A, 18059 Rostock, Germany
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26
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Chevalier G, Aubert N, Thirion-Delalande C, Palate B, Singh P. Carcinogenicity Evaluation of Baclofen in TgrasH2 Mice. Toxicol Pathol 2021; 50:153-157. [PMID: 34814786 DOI: 10.1177/01926233211054767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Baclofen is a γ-aminobutyric acid-B receptor agonist used for control of spastic muscle activity and as a treatment for alcohol abuse. The review of the nonclinical database suggested a data gap for potential carcinogenicity following long-term use. Regulatory requirements for pharmaceutical safety testing of cancer-causing potential have historically included 2-year rodent studies in rats and mice. The availability of transgenic models with greater specificity and sensitivity to carcinogens provides safety testing alternatives that align with the 3Rs. The carcinogenicity of baclofen was evaluated in CB6F1-TgrasH2 transgenic mice following daily oral administration at 45, 90, and 180 mg/kg/d for 26 weeks, preceded by a 2-week drug-conditioning period. There were no treatment-related palpable masses or neoplastic findings, and survival rates were not affected by the baclofen treatment. In conclusion, baclofen was considered as noncarcinogenic in CB6F1-TgrasH2 mice, which is consistent with results previously obtained in a 2-year rat study.
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LaRowe BL, Nussbaum VM. In Support of Initial Parenteral Medical Management of Intrathecal Baclofen Withdrawal in Spasticity Patients. J Pharm Technol 2021; 37:293-297. [PMID: 34790966 DOI: 10.1177/87551225211039237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Spasticity may present as a wide range of symptoms and conditions. With this protean presentation, a consensus regarding the best course of treatment does not exist. Those patients most severely affected may receive significant benefit from intrathecal baclofen delivery. However, this therapy may itself lead to patient injury in the event of withdrawal. Objective: Withdrawal from intrathecal baclofen may devolve rapidly into a situation in which the patient may incur significant morbidity and even death. A focused, prompt treatment plan would afford the patient the best possible outcome. Methods: The medical literature was reviewed for reports of plans of treatment of baclofen withdrawal and the results obtained. The nature of this problem does not lend itself to a typical study design, depending on case reports and basic pharmacological science application. The paucity of such reports severely limits categorical comparison of patient characteristics and clinical circumstances. Clinical situations, patient characteristics, and therapies were considered and compared. Outcomes of the varied treatments were evaluated for efficacy. Results: Inaccurate diagnoses, delayed correct diagnoses, and the absence of a consistent, treatment plan contributed to widely disparate outcomes. Prompt, correct diagnosis and intensive care unit-based continuous benzodiazepine infusion with titration led to a controlled clinical situation and maximized patient outcomes. Conclusions: Patients going through withdrawal from intrathecal baclofen achieved best outcomes when treated with a continuous infusion and titration of an intravenous benzodiazepine. A well-defined treatment protocol employing this management, reporting serial outcomes, would enable further refinement of the treatment of this clinical problem.
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Affiliation(s)
- Brian L LaRowe
- American Family Children's Hospital, University of Wisconsin, Madison, WI, USA
| | - Vicki M Nussbaum
- American Family Children's Hospital, University of Wisconsin, Madison, WI, USA
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Calvert JS, Gill ML, Linde MB, Veith DD, Thoreson AR, Lopez C, Lee KH, Gerasimenko YP, Edgerton VR, Lavrov IA, Zhao KD, Grahn PJ, Sayenko DG. Voluntary Modulation of Evoked Responses Generated by Epidural and Transcutaneous Spinal Stimulation in Humans with Spinal Cord Injury. J Clin Med 2021; 10:jcm10214898. [PMID: 34768418 PMCID: PMC8584516 DOI: 10.3390/jcm10214898] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/20/2021] [Accepted: 10/20/2021] [Indexed: 12/29/2022] Open
Abstract
Transcutaneous (TSS) and epidural spinal stimulation (ESS) are electrophysiological techniques that have been used to investigate the interactions between exogenous electrical stimuli and spinal sensorimotor networks that integrate descending motor signals with afferent inputs from the periphery during motor tasks such as standing and stepping. Recently, pilot-phase clinical trials using ESS and TSS have demonstrated restoration of motor functions that were previously lost due to spinal cord injury (SCI). However, the spinal network interactions that occur in response to TSS or ESS pulses with spared descending connections across the site of SCI have yet to be characterized. Therefore, we examined the effects of delivering TSS or ESS pulses to the lumbosacral spinal cord in nine individuals with chronic SCI. During low-frequency stimulation, participants were instructed to relax or attempt maximum voluntary contraction to perform full leg flexion while supine. We observed similar lower-extremity neuromusculature activation during TSS and ESS when performed in the same participants while instructed to relax. Interestingly, when participants were instructed to attempt lower-extremity muscle contractions, both TSS- and ESS-evoked motor responses were significantly inhibited across all muscles. Participants with clinically complete SCI tested with ESS and participants with clinically incomplete SCI tested with TSS demonstrated greater ability to modulate evoked responses than participants with motor complete SCI tested with TSS, although this was not statistically significant due to a low number of subjects in each subgroup. These results suggest that descending commands combined with spinal stimulation may increase activity of inhibitory interneuronal circuitry within spinal sensorimotor networks in individuals with SCI, which may be relevant in the context of regaining functional motor outcomes.
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Affiliation(s)
- Jonathan S. Calvert
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN 55905, USA;
| | - Megan L. Gill
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA; (M.L.G.); (M.B.L.); (D.D.V.); (A.R.T.); (C.L.); (K.H.L.); (K.D.Z.); (P.J.G.)
| | - Margaux B. Linde
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA; (M.L.G.); (M.B.L.); (D.D.V.); (A.R.T.); (C.L.); (K.H.L.); (K.D.Z.); (P.J.G.)
| | - Daniel D. Veith
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA; (M.L.G.); (M.B.L.); (D.D.V.); (A.R.T.); (C.L.); (K.H.L.); (K.D.Z.); (P.J.G.)
| | - Andrew R. Thoreson
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA; (M.L.G.); (M.B.L.); (D.D.V.); (A.R.T.); (C.L.); (K.H.L.); (K.D.Z.); (P.J.G.)
| | - Cesar Lopez
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA; (M.L.G.); (M.B.L.); (D.D.V.); (A.R.T.); (C.L.); (K.H.L.); (K.D.Z.); (P.J.G.)
| | - Kendall H. Lee
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA; (M.L.G.); (M.B.L.); (D.D.V.); (A.R.T.); (C.L.); (K.H.L.); (K.D.Z.); (P.J.G.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
- Department of Physiology and Biomedical Engineering, Rochester, MN 55905, USA
| | - Yury P. Gerasimenko
- Pavlov Institute of Physiology of Russian Academy of Sciences, 199034 St. Petersburg, Russia;
- Department of Physiology and Biophysics, University of Louisville, Louisville, KY 40292, USA
| | - Victor R. Edgerton
- Department of Integrative Biology and Physiology, University of California Los Angeles, Los Angeles, CA 90095, USA;
- Department of Neurobiology, University of California Los Angeles, Los Angeles, CA 90095, USA
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, CA 90095, USA
- Brain Research Institute, University of California Los Angeles, Los Angeles, CA 90095, USA
- Institut Guttmann, Hospital de Neurorehabilitació, Institut Universitari Adscrit a la Universitat Autònoma de Barcelona, 08916 Badalona, Spain
- Centre for Neuroscience and Regenerative Medicine, Faculty of Science, University of Technology Sydney, Ultimo 2007, Australia
| | - Igor A. Lavrov
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| | - Kristin D. Zhao
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA; (M.L.G.); (M.B.L.); (D.D.V.); (A.R.T.); (C.L.); (K.H.L.); (K.D.Z.); (P.J.G.)
- Department of Physiology and Biomedical Engineering, Rochester, MN 55905, USA
| | - Peter J. Grahn
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA; (M.L.G.); (M.B.L.); (D.D.V.); (A.R.T.); (C.L.); (K.H.L.); (K.D.Z.); (P.J.G.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| | - Dimitry G. Sayenko
- Center for Neuroregeneration, Department of Neurosurgery, Houston Methodist Research Institute, Houston, TX 77030, USA
- Correspondence: ; Tel.: +1-713-363-7949
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Hodge JO, Brandmeir CL, Brandmeir NJ. Neuromodulation Therapies for Spasticity Control: Now and Beyond. Neurol India 2021; 68:S241-S248. [PMID: 33318358 DOI: 10.4103/0028-3886.302464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Spasticity is a major cause of disability following upper motor neuron (UMN) injury. The diagnosis and treatment of spasticity has been a focus of clinicians and researchers alike. In recent years, there have been significant advances both in strategies for spasticity assessment and in the development of novel treatments. Currently, several well-established spasticity management techniques fall into the major categories of physiotherapy, pharmacotherapy, and surgical management. The majority of recent developments in all of these broad categories have focused more on methods of neuromodulation instead of simple symptomatic treatment, attempting to address the underlying cause of spasticity more directly. The following narrative review briefly discusses the causes and clinical assessment of spasticity and also details the wide variety of current and developing treatment approaches for this often-debilitating condition.
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Affiliation(s)
- Johnie O Hodge
- Department of Neurosurgery, Rockefeller Neuroscience Institute, Morgantown, WV, United States
| | - Cheryl L Brandmeir
- Department of Human Performance, West Virginia University, Morgantown, WV, United States
| | - Nicholas J Brandmeir
- Department of Neurosurgery, Rockefeller Neuroscience Institute, Morgantown, WV, United States
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Bilchak JN, Yeakle K, Caron G, Malloy D, Côté MP. Enhancing KCC2 activity decreases hyperreflexia and spasticity after chronic spinal cord injury. Exp Neurol 2021; 338:113605. [PMID: 33453210 PMCID: PMC7904648 DOI: 10.1016/j.expneurol.2021.113605] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/21/2020] [Accepted: 01/09/2021] [Indexed: 02/03/2023]
Abstract
After spinal cord injury (SCI), the majority of individuals develop spasticity, a debilitating condition involving involuntary movements, co-contraction of antagonistic muscles, and hyperreflexia. By acting on GABAergic and Ca2+-dependent signaling, current anti-spastic medications lead to serious side effects, including a drastic decrease in motoneuronal excitability which impairs motor function and rehabilitation efforts. Exercise, in contrast, decreases spastic symptoms without decreasing motoneuron excitability. These functional improvements coincide with an increase in expression of the chloride co-transporter KCC2 in lumbar motoneurons. Thus, we hypothesized that spastic symptoms can be alleviated directly through restoration of chloride homeostasis and endogenous inhibition by increasing KCC2 activity. Here, we used the recently developed KCC2 enhancer, CLP257, to evaluate the effects of acutely increasing KCC2 extrusion capability on spastic symptoms after chronic SCI. Sprague Dawley rats received a spinal cord transection at T12 and were either bike-trained or remained sedentary for 5 weeks. Increasing KCC2 activity in the lumbar enlargement improved the rate-dependent depression of the H-reflex and reduced both phasic and tonic EMG responses to muscle stretch in sedentary animals after chronic SCI. Furthermore, the improvements due to this pharmacological treatment mirror those of exercise. Together, our results suggest that pharmacologically increasing KCC2 activity is a promising approach to decrease spastic symptoms in individuals with SCI. By acting to directly restore endogenous inhibition, this strategy has potential to avoid severe side effects and improve the quality of life of affected individuals.
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Affiliation(s)
- Jadwiga N Bilchak
- Marion Murray Spinal Cord Injury Research Center, Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, United States of America
| | - Kyle Yeakle
- Marion Murray Spinal Cord Injury Research Center, Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, United States of America
| | - Guillaume Caron
- Marion Murray Spinal Cord Injury Research Center, Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, United States of America
| | - Dillon Malloy
- Marion Murray Spinal Cord Injury Research Center, Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, United States of America
| | - Marie-Pascale Côté
- Marion Murray Spinal Cord Injury Research Center, Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, United States of America.
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Jiang MC, Birch DV, Heckman CJ, Tysseling VM. The Involvement of Ca V1.3 Channels in Prolonged Root Reflexes and Its Potential as a Therapeutic Target in Spinal Cord Injury. Front Neural Circuits 2021; 15:642111. [PMID: 33867945 PMCID: PMC8044857 DOI: 10.3389/fncir.2021.642111] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/03/2021] [Indexed: 11/13/2022] Open
Abstract
Spinal cord injury (SCI) results in not only the loss of voluntary muscle control, but also in the presence of involuntary movement or spasms. These spasms post-SCI involve hyperexcitability in the spinal motor system. Hyperactive motor commands post SCI result from enhanced excitatory postsynaptic potentials (EPSPs) and persistent inward currents in voltage-gated L-type calcium channels (LTCCs), which are reflected in evoked root reflexes with different timings. To further understand the contributions of these cellular mechanisms and to explore the involvement of LTCC subtypes in SCI-induced hyperexcitability, we measured root reflexes with ventral root recordings and motoneuron activities with intracellular recordings in an in vitro preparation using a mouse model of chronic SCI (cSCI). Specifically, we explored the effects of 1-(3-chlorophenethyl)-3-cyclopentylpyrimidine-2,4,6-(1H,3H,5H)-trione (CPT), a selective negative allosteric modulator of CaV1.3 LTCCs. Our results suggest a hyperexcitability in the spinal motor system in these SCI mice. Bath application of CPT displayed slow onset but dose-dependent inhibition of the root reflexes with the strongest effect on LLRs. However, the inhibitory effect of CPT is less potent in cSCI mice than in acute SCI (aSCI) mice, suggesting changes either in composition of CaV1.3 or other cellular mechanisms in cSCI mice. For intracellular recordings, the intrinsic plateau potentials, was observed in more motoneurons in cSCI mice than in aSCI mice. CPT inhibited the plateau potentials and reduced motoneuron firings evoked by intracellular current injection. These results suggest that the LLR is an important target and that CPT has potential in the therapy of SCI-induced muscle spasms.
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Affiliation(s)
- Mingchen C Jiang
- Department of Physiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Derin V Birch
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Charles J Heckman
- Department of Physiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States.,Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States.,Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Vicki M Tysseling
- Department of Physiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States.,Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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Gong C, Zheng X, Guo F, Wang Y, Zhang S, Chen J, Sun X, Shah SZA, Zheng Y, Li X, Yin Y, Li Q, Huang X, Guo T, Han X, Zhang SC, Wang W, Chen H. Human spinal GABA neurons alleviate spasticity and improve locomotion in rats with spinal cord injury. Cell Rep 2021; 34:108889. [PMID: 33761348 DOI: 10.1016/j.celrep.2021.108889] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/21/2020] [Accepted: 03/01/2021] [Indexed: 01/10/2023] Open
Abstract
Spinal cord injury (SCI) often results in spasticity. There is currently no effective therapy for spasticity. Here, we describe a method to efficiently differentiate human pluripotent stem cells from spinal GABA neurons. After transplantation into the injured rat spinal cord, the DREADD (designer receptors exclusively activated by designer drug)-expressing spinal progenitors differentiate into GABA neurons, mitigating spasticity-like response of the rat hindlimbs and locomotion deficits in 3 months. Administering clozapine-N-oxide, which activates the grafted GABA neurons, further alleviates spasticity-like response, suggesting an integration of grafted GABA neurons into the local neural circuit. These results highlight the therapeutic potential of the spinal GABA neurons for SCI.
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Affiliation(s)
- ChenZi Gong
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xiaolong Zheng
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - FangLiang Guo
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - YaNan Wang
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Song Zhang
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Jing Chen
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - XueJiao Sun
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Sayed Zulfiqar Ali Shah
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - YiFeng Zheng
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xiao Li
- School of Mechanical Engineering, Hubei University of Technology, Wuhan 430068, China
| | - Yatao Yin
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Qian Li
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - XiaoLin Huang
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Tiecheng Guo
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xiaohua Han
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Su-Chun Zhang
- Waisman Center, Department of Neuroscience and Department of Neurology, University of Wisconsin, Madison, WI, USA; Program in Neuroscience & Behavioral Disorders, Duke-NUS Medical School, Singapore, Singapore
| | - Wei Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
| | - Hong Chen
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
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Teng YD, Zafonte RD. Prelude to the special issue on novel neurocircuit, cellular and molecular targets for developing functional rehabilitation therapies of neurotrauma. Exp Neurol 2021; 341:113689. [PMID: 33745921 DOI: 10.1016/j.expneurol.2021.113689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/07/2021] [Indexed: 11/15/2022]
Abstract
The poor endogenous recovery capacity and other impediments to reinstating sensorimotor or autonomic function after adult neurotrauma have perplexed modern neuroscientists, bioengineers, and physicians for over a century. However, despite limited improvement in options to mitigate acute pathophysiological sequalae, the past 20 years have witnessed marked progresses in developing efficacious rehabilitation strategies for chronic spinal cord and brain injuries. The achievement is mainly attributable to research advancements in elucidating neuroplastic mechanisms for the potential to enhance clinical prognosis. Innovative cross-disciplinary studies have established novel therapeutic targets, theoretical frameworks, and regiments to attain treatment efficacy. This Special Issue contained eight papers that described experimental and human data along with literature reviews regarding the essential roles of the conventionally undervalued factors in neural repair: systemic inflammation, neural-respiratory inflammasome axis, modulation of glutamatergic and monoaminergic neurotransmission, neurogenesis, nerve transfer, recovery neurobiology components, and the spinal cord learning, respiration and central pattern generator neurocircuits. The focus of this work was on how to induce functional recovery from manipulating these underpinnings through their interactions with secondary injury events, peripheral and supraspinal inputs, neuromusculoskeletal network, and interventions (i.e., activity training, pharmacological adjuncts, electrical stimulation, and multimodal neuromechanical, brain-computer interface [BCI] and robotic assistance [RA] devices). The evidence suggested that if key neurocircuits are therapeutically reactivated, rebuilt, and/or modulated under proper sensory feedback, neurological function (e.g., cognition, respiration, limb movement, locomotion, etc.) will likely be reanimated after neurotrauma. The efficacy can be optimized by individualizing multimodal rehabilitation treatments via BCI/RA-integrated drug administration and neuromechanical protheses.
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Affiliation(s)
- Yang D Teng
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA; Neurotrauma Recovery Research, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital Network, Mass General Brigham, and Harvard Medical School, Boston, MA, USA; Spaulding Research Institute, Spaulding Rehabilitation Hospital Network, Boston, MA, USA.
| | - Ross D Zafonte
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA; Neurotrauma Recovery Research, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital Network, Mass General Brigham, and Harvard Medical School, Boston, MA, USA; Spaulding Research Institute, Spaulding Rehabilitation Hospital Network, Boston, MA, USA.
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Malapile RJ, Nyamayaro K, Nassimbeni LR, Báthori NB. Multicomponent crystals of baclofen with acids and bases—conformational flexibility and synthon versatility. CrystEngComm 2021. [DOI: 10.1039/d0ce01522a] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Crystals of baclofen with acidic or basic coformers suggest that the robustness of the hydrogen bonding between the adjacent baclofen molecules aids the formation of the alternating hydrophilic and hydrophobic layers in the crystal structures.
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Affiliation(s)
| | - Kudzanai Nyamayaro
- Department of Chemistry
- Cape Peninsula University of Technology
- Cape Town
- South Africa
| | | | - Nikoletta B. Báthori
- Department of Chemistry
- Cape Peninsula University of Technology
- Cape Town
- South Africa
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A randomized phase 1 single-dose polysomnography study of ASP8062, a GABA B receptor positive allosteric modulator. Psychopharmacology (Berl) 2021; 238:867-876. [PMID: 33433644 PMCID: PMC7914186 DOI: 10.1007/s00213-020-05738-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 12/01/2020] [Indexed: 12/29/2022]
Abstract
RATIONALE Previous research suggests that sleep polysomnography and EEG endpoints can be used to assess GABAergic activity; however, the impact of GABAB receptor positive allosteric modulators on sleep endpoints remains unclear. OBJECTIVES This phase 1 study compared a single dose of ASP8062 (35 mg or 70 mg), a GABAB receptor positive allosteric modulator, with placebo and paroxetine (40 mg). METHODS Healthy adult volunteers were randomized to four treatments (35 mg ASP8062, 70 mg ASP8062, paroxetine 40 mg, or matching placebo), each separated by a 14-day washout. Primary endpoints obtained by polysomnography were time in stage N3 or SWS and time in rapid eye movement (REM) sleep. Secondary endpoints included impact on sleep stages and electroencephalography parameters, pharmacokinetics, nighttime growth hormone (GH), and safety/tolerability. RESULTS In 20 randomized volunteers, ASP8062 led to a significant and seemingly dose-dependent increase in SWS over the entire night; this increase was mainly observed during the first third of the night. ASP8062 did not impact time in REM sleep. Paroxetine had no effect on SWS but produced a significant reduction in time spent in REM sleep. A dose-dependent trend in increased GH release was also observed with ASP8062. Headache and nausea were the most commonly reported treatment-emergent adverse events (TEAEs) for ASP8062; most TEAEs were mild in severity. CONCLUSIONS Single-dose ASP8062 (35 and 70 mg) appeared to result in CNS penetration and enhanced GABAergic activity as measured by increases in slow-wave sleep and growth hormone release.
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Thompson AK, Sinkjær T. Can Operant Conditioning of EMG-Evoked Responses Help to Target Corticospinal Plasticity for Improving Motor Function in People With Multiple Sclerosis? Front Neurol 2020; 11:552. [PMID: 32765389 PMCID: PMC7381136 DOI: 10.3389/fneur.2020.00552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 05/15/2020] [Indexed: 11/25/2022] Open
Abstract
Corticospinal pathway and its function are essential in motor control and motor rehabilitation. Multiple sclerosis (MS) causes damage to the brain and descending connections, and often diminishes corticospinal function. In people with MS, neural plasticity is available, although it does not necessarily remain stable over the course of disease progress. Thus, inducing plasticity to the corticospinal pathway so as to improve its function may lead to motor control improvements, which impact one's mobility, health, and wellness. In order to harness plasticity in people with MS, over the past two decades, non-invasive brain stimulation techniques have been examined for addressing common symptoms, such as cognitive deficits, fatigue, and spasticity. While these methods appear promising, when it comes to motor rehabilitation, just inducing plasticity or having a capacity for it does not guarantee generation of better motor functions. Targeting plasticity to a key pathway, such as the corticospinal pathway, could change what limits one's motor control and improve function. One of such neural training methods is operant conditioning of the motor-evoked potential that aims to train the behavior of the corticospinal-motoneuron pathway. Through up-conditioning training, the person learns to produce the rewarded neuronal behavior/state of increased corticospinal excitability, and through iterative training, the rewarded behavior/state becomes one's habitual, daily motor behavior. This minireview introduces operant conditioning approach for people with MS. Guiding beneficial CNS plasticity on top of continuous disease progress may help to prolong the duration of maintained motor function and quality of life in people living with MS.
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Affiliation(s)
- Aiko K Thompson
- Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston, SC, United States
| | - Thomas Sinkjær
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.,Lundbeck Foundation, Copenhagen, Denmark
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Abstract
Baclofen, β-(4-chlorophenyl)-γ-aminobutyric acid, holds a unique position in neuroscience, remaining the only U.S. Food and Drug Administration (FDA) approved GABAB agonist. While intended to be a more brain penetrant, i.e, ability to cross the blood-brain barrier (BBB), version of GABA (γ-aminobutyric acid) for the potential treatment of epilepsy, baclofen's highly efficacious muscle relaxant properties led to its approval, as a racemate, for the treatment of spasticity. Interestingly, baclofen received FDA approval before its receptor, GABAB, was discovered and its exact mechanism of action was known. In recent times, baclofen has a myriad of off-label uses, with the treatment for alcohol abuse and drug addiction garnering a great deal of attention. This Review aims to capture the >60 year legacy of baclofen by walking through the history, pharmacology, synthesis, drug metabolism, routes of administration, and societal impact of this Classic in chemical neuroscience.
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Affiliation(s)
- Caitlin N. Kent
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
- Department of Chemistry, Vanderbilt Institute of Chemical Biology, Vanderbilt University, Nashville, Tennessee 37232, United States
| | - Charlotte Park
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Craig W. Lindsley
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
- Department of Chemistry, Vanderbilt Institute of Chemical Biology, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Biochemistry, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
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38
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Beverungen H, Klaszky SC, Klaszky M, Côté MP. Rehabilitation Decreases Spasticity by Restoring Chloride Homeostasis through the Brain-Derived Neurotrophic Factor-KCC2 Pathway after Spinal Cord Injury. J Neurotrauma 2020; 37:846-859. [PMID: 31578924 PMCID: PMC7071070 DOI: 10.1089/neu.2019.6526] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Activity-based therapy is routinely integrated in rehabilitation programs to facilitate functional recovery after spinal cord injury (SCI). Among its beneficial effects is a reduction of hyperreflexia and spasticity, which affects ∼75% of the SCI population. Unlike current anti-spastic pharmacological treatments, rehabilitation attenuates spastic symptoms without causing an active depression in spinal excitability, thus avoiding further interference with motor recovery. Understanding how activity-based therapies contribute to decrease spasticity is critical to identifying new pharmacological targets and to optimize rehabilitation programs. It was recently demonstrated that a decrease in the expression of KCC2, a neuronal Cl- extruder, contributes to the development spasticity in SCI rats. Although exercise can decrease spinal hyperexcitability and increase KCC2 expression on lumbar motoneurons after SCI, a causal effect remains to be established. Activity-dependent processes include an increase in brain-derived neurotrophic factor (BDNF) expression. Interestingly, BDNF is a regulator of KCC2 but also a potent modulator of spinal excitability. Therefore, we hypothesized that after SCI, the activity-dependent increase in KCC2 expression: 1) functionally contributes to reduce hyperreflexia, and 2) is regulated by BDNF. SCI rats chronically received VU0240551 (KCC2 blocker) or TrkB-IgG (BDNF scavenger) during the daily rehabilitation sessions and the frequency-dependent depression of the H-reflex, a monitor of hyperreflexia, was recorded 4 weeks post-injury. Our results suggest that the activity-dependent increase in KCC2 functionally contributes to H-reflex recovery and critically depends on BDNF activity. This study provides a new perspective in understanding how exercise impacts hyperreflexia by identifying the biological basis of the recovery of function.
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Affiliation(s)
- Henrike Beverungen
- Department of Neurobiology and Anatomy, Marion Murray Spinal Cord Research Center, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Samantha Choyke Klaszky
- Department of Neurobiology and Anatomy, Marion Murray Spinal Cord Research Center, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Michael Klaszky
- Department of Neurobiology and Anatomy, Marion Murray Spinal Cord Research Center, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Marie-Pascale Côté
- Department of Neurobiology and Anatomy, Marion Murray Spinal Cord Research Center, Drexel University College of Medicine, Philadelphia, Pennsylvania
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Reynoard J, Schmitt C, Torrents R, Simon N. Toxicological considerations in the prescription of baclofen for the treatment of substance use disorders. Expert Opin Drug Metab Toxicol 2020; 16:309-317. [PMID: 32149546 DOI: 10.1080/17425255.2020.1740681] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: For many years, applications for baclofen have widened in the treatment of substance abuse disorder (SUD), mainly alcohol use disorder, with a growing rate of off-label prescriptions in Europe. Clinical effects seem to be both a decrease of craving and anxiety, leading to a decrease of drug or alcohol consumption. We described baclofen poisoning circumstances, therapeutic options and outcomes when used in substance use disorders.Areas covered: This review summarizes the toxicological considerations where baclofen was prescribed in humans for substance use or abuse disorder in randomized clinical trials, case series, case reports and observational studies between 1990 and 2020 according to the Preferred Reporting Items for Systemic reviews and Meta-Analysis.Expert opinion: The most frequent cause of severe intoxication is self-poisoning. A dose above 180 mg are expected to cause severe toxicity and death. The treatment is only symptomatic as no antidote is available. Off-label prescription remains unsafe because the optimal dose is not known and varies greatly between patients. As SUD are frequently associated with psychiatric disorders and such patients may have suicidal thoughts, the risk of self-poisoning is high. Potential co-ingestants should also be considered, especially CNS depressants, and they need to be closely monitored.
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Affiliation(s)
- Julien Reynoard
- Pharmacologie Clinique CAP-TV, APHM, Hôpitaux Sud, Marseille, France
| | - Corinne Schmitt
- Pharmacologie Clinique CAP-TV, APHM, Hôpitaux Sud, Marseille, France
| | - Romain Torrents
- APHM, INSERM, IRD, SESSTIM, Hôpital Sainte Marguerite Pharmacologie Clinique CAP-TV, Aix Marseille Univ, Marseille, France
| | - Nicolas Simon
- APHM, INSERM, IRD, SESSTIM, Hôpital Sainte Marguerite Pharmacologie Clinique CAP-TV, Aix Marseille Univ, Marseille, France
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Murai N, Kondo Y, Akuzawa S, Mihara T, Shiraishi N, Kakimoto S, Matsumoto M. A novel GABAB receptor positive allosteric modulator, ASP8062, exerts analgesic effects in a rat model of fibromyalgia. Eur J Pharmacol 2019; 865:172750. [DOI: 10.1016/j.ejphar.2019.172750] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 10/11/2019] [Accepted: 10/18/2019] [Indexed: 11/24/2022]
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Respiratory dysfunction following initiation of mirabegron: A case report. Respir Med Case Rep 2019; 26:304-306. [PMID: 30886821 PMCID: PMC6402286 DOI: 10.1016/j.rmcr.2019.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 02/04/2023] Open
Abstract
Background: Mirabegron, a β3 adrenergic receptor agonist, is FDA approved for treatment of overactive bladder. Approved in 2012 in the US, there have been no reports of any effects of mirabegron on pulmonary function. Case presentation: We report the case of a 65 year old male with a history of Parkinson's disease, OSA, and aspiration pneumonia presenting with subacute worsening dyspnea and found to have worsening restrictive ventilatory defect with a pattern consistent with neuromuscular weakness. After recalling that initiation of mirabegron correlated with onset of his worsening symptoms, the patient decided to perform a trial period off the drug. He subsequently reported prompt improvement in his respiratory symptoms, which was confirmed objectively by pulmonary function tests. In this case, mirabegron was temporally associated with subacute worsening of the patient's pulmonary restrictive physiology, with subsequent resolution after discontinuation of the medication. Conclusions: The mechanism of this adverse effect is unknown, but we speculate that this effect may be potentially mediated by the effect of β3 adrenergic receptor agonism on skeletal muscle, in this case in a patient with pre-existing neuromuscular disease. Careful assessment of patients who develop shortness of breath while on mirabegron should include an assessment for restrictive lung disease secondary neuromuscular dysfunction. Additional study is needed of the effects of β3 agonism on skeletal muscle.
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Riedel P, Marino MH. Pharmacologic Treatment Tools: Systemic Medications and Toxins, Opportunities, and Pitfalls. Phys Med Rehabil Clin N Am 2019; 29:501-517. [PMID: 30626511 DOI: 10.1016/j.pmr.2018.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Treatment of pathologic muscle overactivity associated with upper motor neuron syndrome can be multifaceted. One of the initial decisions to be made when formulating an overarching treatment plan is selecting a combination of strategies that is most applicable. Strategies may include physical interventions, such as stretching or splinting modalities, or surgery, whereas pharmacotherapeutic strategies encompass oral/systemic medications as well as agents, such as toxins and alcohols, used for focal chemodenervation. This article reviews the oral/systemic therapies as well as toxins that are used focally. Although medication can also be administered via intrathecal pumps, this treatment approach is discussed elsewhere.
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Affiliation(s)
- Peter Riedel
- Physical Medicine and Rehabilitation, Moss Rehab, 60 Township Line Road, Elkins Park, PA 19027, USA
| | - Michael H Marino
- Physical Medicine and Rehabilitation, Moss Rehab, 60 Township Line Road, Elkins Park, PA 19027, USA; Physical Medicine and Rehabilitation, ReMed, 16 Industrial Boulevard, Paoli, PA 19301, USA.
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Jamshidi N, Morley KC, Cairns R, Dawson A, Haber PS. A Review of Baclofen Overdoses in Australia: Calls to a Poisons Information Centre and a Case Series. Alcohol Alcohol 2018; 54:73-78. [DOI: 10.1093/alcalc/agy082] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 10/29/2018] [Indexed: 01/02/2023] Open
Affiliation(s)
- Nazila Jamshidi
- Drug Health Services, Royal Prince Alfred Hospital, NSW, Australia
| | - Kirsten C Morley
- School of Medicine, NHMRC Centre of Research Excellence in Mental Health and Substance Use, Central Clinical School, Sydney Medical School, University of Sydney, NSW, Australia
| | - Rose Cairns
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, Australia
| | - Andrew Dawson
- Drug Health Services, Royal Prince Alfred Hospital, NSW, Australia
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, Australia
- Central Clinical School, Royal Prince Alfred Hospital, University of Sydney, Sydney
| | - Paul S Haber
- Drug Health Services, Royal Prince Alfred Hospital, NSW, Australia
- School of Medicine, NHMRC Centre of Research Excellence in Mental Health and Substance Use, Central Clinical School, Sydney Medical School, University of Sydney, NSW, Australia
- Central Clinical School, Royal Prince Alfred Hospital, University of Sydney, Sydney
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Abstract
BACKGROUND Alcohol use disorder (AUD) and alcohol-related impairments belong to the most widespread psychiatric disorders leading to specific psychophysical, affective and cognitive symptoms and consequences for psychosocial well-being and health. Alcohol consumption is increasingly becoming a problem in many developing regions and AUD prevalence is estimated at 4.1% worldwide, with highest prevalence in European countries (7.5%), and the North America (6.0%). Therapeutic approaches, including pharmacotherapy, play an important role in treating patients with AUD. OBJECTIVES To assess the efficacy and safety of baclofen for treating people with AUD, who are currently drinking, with the aim of achieving and maintaining abstinence or reducing alcohol consumption. SEARCH METHODS We searched the Cochrane Drugs and Alcohol Specialised Register, CENTRAL, MEDLINE, Embase, two further databases and two clinical trials registries, conference proceedings, and the reference lists of retrieved articles. The date of the most recent search was 30 January 2018. SELECTION CRITERIA Randomised controlled trials (RCTs) of at least four weeks' treatment duration and 12 weeks' overall study duration comparing baclofen for relapse prevention of AUD with placebo, no treatment or other treatments. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 12 RCTs (1128 participants). All studies but three recruited fewer than 100 participants. Participants had a diagnosis of alcohol dependence according the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV or the International Classification of Diseases (ICD)-10 criteria who were currently drinking. The mean age of participants was 48 years, and there were more men (69%), than women. All studies compared baclofen to placebo, except for one study that evaluated baclofen versus acamprosate. The included studies considered baclofen at different doses (range 10 mg a day to 150 mg a day). In all but one of the studies, participants in both the baclofen and placebo groups received psychosocial treatment or counselling of various intensity.We judged most of the studies at low risk of selection, performance, detection (subjective outcome), attrition and reporting bias.We did not find any difference between baclofen and placebo for the primary outcomes: relapse-return to any drinking (RR 0.88, 95% CI 0.74 to 1.04; 5 studies, 781 participants, moderate certainty evidence); frequency of use by percentage of days abstinent (MD 0.39, 95% CI -11.51 to 12.29; 6 studies, 465 participants, low certainty evidence) and frequency of use by percentage of heavy drinking days at the end of treatment (MD 0.25, 95% CI -1.25 to 1.76; 3 studies, 186 participants, moderate certainty evidence); number of participants with at least one adverse event (RR 1.04, 95% CI 0.99 to 1.10; 4 studies, 430 participants, high certainty evidence); the dropout rate at the end of treatment (RR 0.98, 95% CI 0.77 to 1.26, 8 studies, 977 participants, high certainty evidence) and dropout due to adverse events (RR 1.11, 95% CI 0.59 to 2.07; 7 studies, 913 participants, high certainty evidence).We found evidence that baclofen increases amount of use (drink per drinking days), (MD 1.55, 95% CI 1.32 to 1.77; 2 studies, 72 participants, low certainty evidence).Among secondary outcomes, there was no difference on craving (MD 1.38, 95% CI -1.28 to 4.03, 5 studies, 469 participants), and anxiety (SMD 0.07, 95% CI -0.14 to 0.28; 5 trials, 509 participants). We found that baclofen increased depression (SMD 0.27, 95% CI 0.05 to 0.48; 3 studies, 387 participants).Concerning the specific adverse events we found that baclofen increased: vertigo (RR 2.16, 95% CI 1.24 to 3.74; 7 studies, 858 participants), somnolence/sedation (RR 1.48, 95%CI 1.11 to 1.96; 8 studies, 946 participants), paraesthesia (RR 4.28, 95% CI 2.11 to 8.67; 4 studies, 593 participants), and muscle spasms/rigidity (RR 1.94, 95%CI 1.08 to 3.48; 3 studies, 551 participants). For all the other adverse events we did not find significant differences between baclofen and placebo.For the comparison baclofen versus acamprosate, we were only able to extract data for one outcome, craving. For this outcome, we found that baclofen increased craving compared with acamprosate (MD 14.62, 95% CI 12.72 to 16.52; 1 study, 49 participants). AUTHORS' CONCLUSIONS None of the primary or secondary outcomes of the review showed evidence of a difference between baclofen and placebo. The high heterogeneity among primary studies results limits the interpretation of the summary estimate, the identification of moderators and mediators of baclofen's effects on alcohol use remains a challenge for further research. Even though some results from RCTs are promising, current evidence remains uncertain regarding the use of baclofen as a first-line treatment for people with AUDs.
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Affiliation(s)
- Silvia Minozzi
- Lazio Regional Health ServiceDepartment of EpidemiologyVia Cristoforo Colombo, 112RomeItaly00154
| | - Rosella Saulle
- Lazio Regional Health ServiceDepartment of EpidemiologyVia Cristoforo Colombo, 112RomeItaly00154
| | - Susanne Rösner
- Forel KlinikIslikonerstrasse 5Ellikon an der ThurSwitzerland8548
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45
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Winter G, Beni-Adani L, Ben-Pazi H. Intrathecal Baclofen Therapy-Practical Approach: Clinical Benefits and Complication Management. J Child Neurol 2018; 33:734-741. [PMID: 30009656 DOI: 10.1177/0883073818785074] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intrathecal baclofen is an expanding accepted treatment for children with cerebral palsy and other causes of spasticity and dystonia. The aims of this review are therefore to (1) delineate the clinical benefits of intrathecal baclofen therapy in pediatric spasticity and dystonia and (2) increase awareness of the potential complications and emergency management measures of intrathecal baclofen therapy. A current literature review demonstrates the benefits and complications of this minimally invasive device. Practical guides for recognizing acute conditions and management recommendations are included. Intrathecal baclofen is increasingly being used to help individuals attain realistic functional goals. Therefore, families and health care professionals should be aware of potential complications, symptoms, and emergency management.
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Affiliation(s)
- Gidon Winter
- 1 Pediatric Movement Disorders, Neuropediatric Unit, Shaare Zedek Medical Center, Jerusalem
| | - Liana Beni-Adani
- 2 Pediatric Neurosurgery, Shaare Zedek Medical Center, Jerusalem
| | - Hilla Ben-Pazi
- 1 Pediatric Movement Disorders, Neuropediatric Unit, Shaare Zedek Medical Center, Jerusalem
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Caruso P, Mazzon G, Sarra VM, Tacconi L, Manganotti P. The use ultrasound guided for refilling intrathecal baclofene pump in complicated clinical cases: A practical approach. J Clin Neurosci 2018; 57:194-197. [PMID: 30193899 DOI: 10.1016/j.jocn.2018.08.040] [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: 04/18/2018] [Accepted: 08/13/2018] [Indexed: 11/15/2022]
Abstract
Muscular spasticity due to neurological disorders is a heavy cause of severe pain and disability for many patients, compromising the independence and quality life. Baclofene is a good tool to guarantee patients independence and pain control. Anyway in chronic therapy oral treatment become unsatisfactory. In all these cases, intrathecal baclofen therapy (ITB), after sub fascial implantation of intrathecal pumps is used as an important long term treatment to reduce spasticity. After pump implantation the drug reservoir must be refilled periodically in order to maintain the reduction of spasticity and avoid the symptoms and signs of withdrawal. ITB refilling, which involves the insertion of a needle through the skin until the access port of the pump, is often hard, mainly due to the layer of abdominal fat, spasticity, suboptimal pump positioning, pump rotation or inversion, and scar formation over the implantation site. To avoid the difficulties of ITB refilling radiography or other invasive supportive examinations are sometimes needed. We reported here our experience and we suggest a simple method to use the ultrasound in refilling with particular attention to some cases with complications after implantation with a difficult approach in refilling. We used the ultrasound examination to identify the access port of her pump so as to avoid multiple needle punctures and infections and radiation exposition. Ultrasound-guided technique may facilitate ITB refill in technically challenging cases. With ultrasound ITB was easily detectable and was quite simple to identify the exact point of needle injection. In the last years different new applications for ultrasounds are emerging. In our opinion the use of Doppler ultrasounds in the study of muscles and nerves represent an emerging tool for the physician's neurological rehabilitation.
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Affiliation(s)
- P Caruso
- Unit of Clinical Neurology Department of Medical Sciences, University of Trieste, University Hospital and Health Services of Trieste, Italy.
| | - G Mazzon
- Unit of Clinical Neurology Department of Medical Sciences, University of Trieste, University Hospital and Health Services of Trieste, Italy
| | - V M Sarra
- Unit of Clinical Neurology Department of Medical Sciences, University of Trieste, University Hospital and Health Services of Trieste, Italy
| | - L Tacconi
- Unit of Clinical Neurology Department of Medical Sciences, University of Trieste, University Hospital and Health Services of Trieste, Italy
| | - P Manganotti
- Unit of Clinical Neurology Department of Medical Sciences, University of Trieste, University Hospital and Health Services of Trieste, Italy
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Chan DY, Chan SS, Chan EK, Ng AY, Ying AC, Li AC, Chiu CC, Cheung N, Mak W, Sun DT, Zhu CX, Poon W. Blessing or burden? Long-term maintenance, complications and clinical outcome of intrathecal baclofen pumps. SURGICAL PRACTICE 2018; 22:105-110. [PMID: 30147745 PMCID: PMC6099513 DOI: 10.1111/1744-1633.12308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/10/2018] [Indexed: 12/01/2022]
Abstract
AIM The intrathecal baclofen pump is an effective treatment for spasticity. However, long-term results have reported patients' dissatisfaction and perception of disability. Potential causes include a frequent need for baclofen pump refill and risks of complications. The aim of the present study was to evaluate the long-term maintenance, complications and clinical outcome of intrathecal baclofen pumps. PATIENTS AND METHODS We conducted a 16-year retrospective cohort study of patients with spasticity treated with an intrathecal baclofen pump at a university hospital from 2000 to 2016. The primary outcome was the rate of infection per puncture for baclofen pump refill. Secondary outcomes included the incidence of other complications, such as running out of baclofen causing symptomatic withdrawal symptoms, pump mechanical failure, pump battery end of life and the need for pump replacement. The clinical outcome was assessed by the Modified Ashworth Scale (mAS). RESULTS In total, 340 follow-up episodes with pump refill procedures were recorded. The average interval between each pump refill was 57.3 days (±15.4 days). The average duration of admission for each pump refill was 4 h and 49 min (from 2 h 23 min to 10 h). There were two events with established infection after puncture for the refill, giving rise to an infection rate per puncture of 0.6 percent (2/340).For the long-term clinical outcome, at an average follow-up period of 7.6 years, the postoperative mAS for spasticity was 2.0 ± 0.756, which was significantly better than the preoperative mAS at 3.75 ± 0.462 (P = 0.001). CONCLUSION Long-term aftercare with baclofen pump refill was safe, with an infection rate of 0.6 per cent per puncture for each refill. Long-term intrathecal baclofen pump was effective in the treatment of spasticity with persistent significant improvement in the spasticity scale.
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Affiliation(s)
- David Yuen‐Chung Chan
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - Steve Sik‐Kwan Chan
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - Emily Kit‐Ying Chan
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - Amelia Yikjin Ng
- Anaesthesia and Intensive Care, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong
| | - Aaron Chee‐Lun Ying
- Anaesthesia and Intensive Care, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong
| | - Ara Cheuk‐Yin Li
- Anaesthesia and Intensive Care, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong
| | - Candy Ching‐Pik Chiu
- Anaesthesia and Intensive Care, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong
| | - Ning Cheung
- Anaesthesia and Intensive Care, Prince of Wales HospitalThe Chinese University of Hong KongHong Kong
| | - Wai‐Kit Mak
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - David Tin‐Fung Sun
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - Cannon Xian‐Lun Zhu
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
| | - Wai‐Sang Poon
- Division of Neurosurgery, Departments of SurgeryThe Chinese University of Hong KongHong Kong
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Eftekhar A, Norton JJS, McDonough CM, Wolpaw JR. Retraining Reflexes: Clinical Translation of Spinal Reflex Operant Conditioning. Neurotherapeutics 2018; 15:669-683. [PMID: 29987761 PMCID: PMC6095771 DOI: 10.1007/s13311-018-0643-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Neurological disorders, such as spinal cord injury, stroke, traumatic brain injury, cerebral palsy, and multiple sclerosis cause motor impairments that are a huge burden at the individual, family, and societal levels. Spinal reflex abnormalities contribute to these impairments. Spinal reflex measurements play important roles in characterizing and monitoring neurological disorders and their associated motor impairments, such as spasticity, which affects nearly half of those with neurological disorders. Spinal reflexes can also serve as therapeutic targets themselves. Operant conditioning protocols can target beneficial plasticity to key reflex pathways; they can thereby trigger wider plasticity that improves impaired motor skills, such as locomotion. These protocols may complement standard therapies such as locomotor training and enhance functional recovery. This paper reviews the value of spinal reflexes and the therapeutic promise of spinal reflex operant conditioning protocols; it also considers the complex process of translating this promise into clinical reality.
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Affiliation(s)
- Amir Eftekhar
- National Center for Adaptive Neurotechnologies, Wadsworth Center, New York State Department of Health, Albany, NY, USA.
| | - James J S Norton
- National Center for Adaptive Neurotechnologies, Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | - Christine M McDonough
- School of Health and Rehabilitation Services, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan R Wolpaw
- National Center for Adaptive Neurotechnologies, Wadsworth Center, New York State Department of Health, Albany, NY, USA
- Department of Neurology, Stratton VA Medical Center, Albany, NY, USA
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Campbell EJ, Lawrence AJ, Perry CJ. New steps for treating alcohol use disorder. Psychopharmacology (Berl) 2018; 235:1759-1773. [PMID: 29574507 DOI: 10.1007/s00213-018-4887-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 03/16/2018] [Indexed: 12/31/2022]
Abstract
Alcohol use disorder is a complex syndrome with multiple treatment points including drug-induced pathology, withdrawal management, behavioral/cognitive strategies, and relapse prevention. These different components may be complicated by genotype and phenotype. A huge milestone for the treatment of alcohol use disorder across several countries in the last 10 years was the introduction of practice guidelines integrating clinical expertise and research evidence. These provide a summary of interventions that have been shown to be effective following rigorous and replicated clinical trials. Inspection of these guidelines reveals good consistency, but little evidence of progress in treatment approaches for alcohol use disorder over the past decade. In this mini-review, we discuss emerging treatments for alcohol use disorder that may supplement or improve the evidence-based treatments that are currently recommended. New medications, the emergence of digital technology, and other novel approaches such as transcranial magnetic stimulation are all discussed with reference to treatments already in practice. We also consider how individual differences in genotype and phenotype may affect outcomes. Together with improvements in technology, this knowledge offers a powerful tool for designing personalized approaches to treatment, and hence improving prognosis for rehabilitation programs.
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Affiliation(s)
- Erin J Campbell
- The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Parkville, Victoria, 3052, Australia.,Florey Department of Neuroscience and Mental Health, The University of Melbourne, Parkville, Victoria, 3010, Australia
| | - Andrew J Lawrence
- The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Parkville, Victoria, 3052, Australia.,Florey Department of Neuroscience and Mental Health, The University of Melbourne, Parkville, Victoria, 3010, Australia
| | - Christina J Perry
- The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Parkville, Victoria, 3052, Australia. .,Florey Department of Neuroscience and Mental Health, The University of Melbourne, Parkville, Victoria, 3010, Australia.
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50
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Sitthinamsuwan B, Khampalikit I, Phonwijit L, Nitising A, Nunta-Aree S, Suksompong S. Dorsal Longitudinal T-Myelotomy (Bischof II Technique): A Useful, Antiquated Procedure for the Treatment of Intractable Spastic Paraplegia. World Neurosurg 2018; 116:e476-e484. [PMID: 29753900 DOI: 10.1016/j.wneu.2018.05.008] [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: 11/09/2017] [Revised: 05/01/2018] [Accepted: 05/02/2018] [Indexed: 10/16/2022]
Abstract
OBJECTIVE Dorsal longitudinal T-myelotomy is a long-established operation to treat severe spastic paraplegia. The present study aimed to report this surgical technique and investigate the efficacy of T-myelotomy for spasticity relief. METHODS All cases undergoing T-myelotomy for treatment of intractable spastic paraplegia during 2009-2017 were included. The severity of spasticity was evaluated with the Modified Ashworth Scale, Penn Spasm Frequency Scale, Adductor Tone Rating Scale, degree of passive range of motion, and occurrence of abdominal muscle spasms. Other clinical assessments included deep tendon reflex assessed by the National Institute of Neurological Disorders and Stroke scale, Babinski sign, healing of decubitus ulcers, and ambulatory status. RESULTS Fourteen patients with a mean age of 39.3 ± 13.4 years were included. The 7 patients with abdominal muscle spasms before surgery had no spasms after surgery. The Babinski sign was absent in all cases after surgery. Unhealed pressure ulcers in all 9 cases were healed after surgery. All 4 patients with a preoperative bed-bound condition were able to ambulate with a wheelchair. A statistically significant improvement in mean Modified Ashworth Scale score, degree of passive range of motion, and National Institute of Neurological Disorders and Stroke scale score was found in the subgroup and overall analyses. There was also a statistically significant improvement in the Penn Spasm Frequency Scale and Adductor Tone Rating Scale scores. CONCLUSIONS Dorsal longitudinal T-myelotomy remains an effective option for the treatment of intractable spastic paraplegia. It is suitable for, and may be an alternative to, intrathecal baclofen therapy for patients with complete spinal cord lesion or patients without hope of regaining motor function.
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Affiliation(s)
- Bunpot Sitthinamsuwan
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Inthira Khampalikit
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Luckchai Phonwijit
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Akkapong Nitising
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sarun Nunta-Aree
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sirilak Suksompong
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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