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Mariniello A, Nasti T, Chang D, Malik S, McManus D, McGuire D, Buchwald Z, Novello S, Sangiolo D, Scagliotti G, Ramalingam S, Ahmed R. 222P Platinum-based chemotherapy attenuates the CD8 T cell proliferative response to concomitant PD-1 blockade. Immuno-Oncology and Technology 2022. [DOI: 10.1016/j.iotech.2022.100333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Oyama K, Raz I, Cahn A, Goodrich E, Bhatt D, Leiter L, McGuire D, Wilding J, Gause-Nilsson I, Mosenzon O, Sabatine M, Wiviott S. Influence of cardiovascular drugs on the efficacy and safety of dapagliflozin in patients with type 2 diabetes mellitus in the DECLARE-TIMI 58 trial. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
In DECLARE-TIMI 58, the sodium glucose co-transporter 2 inhibitor (SGLT2i) dapagliflozin reduced the risk of the composite of cardiovascular (CV) death or hospitalization for heart failure (HHF) in a broad range of patients with type 2 diabetes mellitus (T2DM). SGLT2i are known to have diuretic and anti-hypertensive effects. However, whether concomitant CV drugs influence the efficacy and safety of dapagliflozin in these populations is less well known.
Purpose
We examined whether dapagliflozin consistently reduced the risk of CV outcomes and whether the safety of dapagliflozin was similar with or without the concurrent use of various CV drugs.
Methods
DECLARE–TIMI 58 was a randomized trial of dapagliflozin versus placebo in patients with T2DM and either atherosclerotic cardiovascular disease (ASCVD) or multiple risk factors for CV disease followed for a median of 4.2 years. We stratified patients by the use of CV drugs at baseline commonly used for heart failure: angiotensin-converting-enzyme inhibitors or angiotensin-receptor blockers (ACEi/ARB), beta-blockers, diuretics, and mineralocorticoid receptor antagonists (MRA). Efficacy outcomes of interest were the composite of CV death/HHF and HHF alone. We used the Cox proportional-hazard model for these analyses.
Results
Of 17,160 patients, 13,950 (81%) used ACEi/ARB, 9,030 (53%) used beta-blockers, 6,967 (41%) used diuretics, and 762 (4%) used MRA at baseline. All were balanced by randomized treatment groups. Patients using CV drugs at baseline had a greater prevalence of atherosclerotic risk factors and established CV disease than those without. Dapagliflozin consistently reduced the risk of CV death/HHF regardless of the use of CV medications (Figure). For HHF alone, similar results were seen with no significant interactions for any of the classes. There were no significant treatment interactions by the concomitant use of any of CV drugs for adverse events including symptoms of volume depletion or acute kidney injury.
Conclusions
In this analysis from the DECLARE–TIMI 58 trial, dapagliflozin consistently reduced the risk of CV death/HHF and HHF alone irrespective of the concurrent use of various CV drugs without any treatment interaction for key safety events.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): The DECLARE–TIMI 58 trial was supported by AstraZeneca.
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Affiliation(s)
- K Oyama
- Brigham and Women's Hospital, Harvard Medical School, Division of Cardiovascular Medicine, Boston, United States of America
| | - I Raz
- Hadassah-Hebrew University Medical Center, Diabetes Unit, Jerusalem, Israel
| | - A Cahn
- Hadassah-Hebrew University Medical Center, Diabetes Unit, Jerusalem, Israel
| | - E Goodrich
- Brigham and Women's Hospital, Harvard Medical School, Division of Cardiovascular Medicine, Boston, United States of America
| | - D Bhatt
- Brigham and Women's Hospital, Harvard Medical School, Division of Cardiovascular Medicine, Boston, United States of America
| | - L Leiter
- University of Toronto, Toronto, Canada
| | - D McGuire
- University of Texas Southwestern Medical Center, Division of Cardiology, Dallas, United States of America
| | - J Wilding
- University of Liverpool, Department of Cardiovascular and Metabolic Medicine, Liverpool, United Kingdom
| | | | - O Mosenzon
- Hadassah-Hebrew University Medical Center, Diabetes Unit, Jerusalem, Israel
| | - M Sabatine
- Brigham and Women's Hospital, Harvard Medical School, Division of Cardiovascular Medicine, Boston, United States of America
| | - S Wiviott
- Brigham and Women's Hospital, Harvard Medical School, Division of Cardiovascular Medicine, Boston, United States of America
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McGuire D, Bowes M, Brett A, Segal NA, Miller M, Rosen D, Kumagai Y. Study TPX-100-5: intra-articular TPX-100 significantly delays pathological bone shape change and stabilizes cartilage in moderate to severe bilateral knee OA. Arthritis Res Ther 2021; 23:242. [PMID: 34535197 PMCID: PMC8447757 DOI: 10.1186/s13075-021-02622-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 09/05/2021] [Indexed: 11/18/2022] Open
Abstract
Background TPX-100, a promotor of osteoblast and chondroblast differentiation, is a potential osteoarthritis (OA) therapy. This retrospective study compared MRI 3D femoral bone shape changes (B-scores) after intra-articular TPX-100 or placebo and analyzed the relationship between cartilage thickness and bone shape change over 12 months. Methods One hundred and four participants with bilateral moderate to severe knee cartilage defects were randomized to receive TPX-100 (200 mg) or placebo. Each subject’s contralateral placebo-treated knee served as a paired internal control. After MRI quality control, 78/93 subjects (84%; 156 knees) were analyzed for quantitative femoral B-score and cartilage thickness. All analyses were performed centrally, blind to treatment assignment and clinical data. Results TPX-100-treated knees (n = 78) demonstrated a statistically significant decrease in pathologic bone shape change compared with placebo-treated knees at 6 and 12 months: 0.0298 (95% C.I. − 0.037, 0.097) vs 0.1246 (95% C.I. 0.067, 0.182) (P = 0.02), and 0.0856 (95% C.I. 0.013, 0.158) vs. 0.1969 (95% C.I. 0.123, 0.271) (P = 0.01), respectively. The correlation between bone shape change and medial and total tibiofemoral cartilage thickness changes at 12 months was statistically significant in TPX-100-treated knees (P < 0.01). Conclusions This is the first report of a potential therapy demonstrating a significant effect on bone shape measured by B-score in knee OA. These data, in combination with previously reported statistically significant and clinically meaningful improvements in WOMAC physical function versus placebo, support TPX-100 as a candidate for disease modification in knee OA. Trial registration NIH ClinicalTrials.gov, NCT01925261. Registered 15 August 2013 Supplementary Information The online version contains supplementary material available at 10.1186/s13075-021-02622-8.
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Affiliation(s)
| | | | | | - Neil A Segal
- University of Kansas Medical Center, Kansas City, KS, USA
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McGuire D, Zinman B, Inzucchi SE, Anker SD, Wanner C, Kaspers S, Von Eynatten M, Johansen OE, Elsasser U, Pocock S, Fitchett D, Jamal W, Hantel S, Lund SS. P6270Empagliflozin reduces the total burden of first and recurrent hospitalisations in patients with type 2 diabetes and established cardiovascular disease. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and aims
The EMPA-REG OUTCOME trial included patients with type 2 diabetes (T2D) and established atherosclerotic cardiovascular (CV) disease. Empagliflozin reduced the risk of 3-point major adverse CV events (MACE; composite of CV death, myocardial infarction [MI], or stroke) by 14%, CV death by 38% and hospitalisation for heart failure (HF) by 35% vs placebo in analyses of time to first event. We assessed the effect of empagliflozin on all-cause hospitalisation in post-hoc analyses of all (first and recurrent) events.
Materials and methods
Patients were randomised to receive empagliflozin 10 mg, empagliflozin 25 mg, or placebo in addition to standard of care. We assessed the effects of empagliflozin pooled vs placebo on first event of all-cause hospitalisation using Cox regression and all (first and recurrent) events of all-cause hospitalisation using a negative binomial model.
Results
A total of 7020 patients were treated (4687 empagliflozin; 2333 placebo, mean [SD] age 63 [9] years, 71% male, 47% with history of MI, 23% with history of stroke, 10% with HF). In this analysis, 1725/4687 (36.8%) empagliflozin patients and 925/2333 (39.6%) placebo patients experienced an event leading to hospitalisation. The adjusted hazard ratio (HR; 95% CI) vs placebo for first all-cause hospitalisation using the Cox regression model was 0.89 (0.82, 0.96; p=0.0033; Figure); In analyses of all (first and recurrent) hospitalisation events, there were 3168 events in the empagliflozin group and 1863 in the placebo group. The adjusted event rate ratio (95% CI) vs placebo was 0.83 (0.76, 0.91; p<0.0001; Figure).
Conclusion
In the EMPA-REG OUTCOME trial, risk reductions with empagliflozin were seen in both first and all hospitalisation events and were numerically more favourable in analyses of all events vs analyses of first events. These analyses expand on the favourable CV effects of empagliflozin by also showing a reduction in the total burden of hospitalisation events in patients with T2D and established CV disease.
Acknowledgement/Funding
Boehringer Ingelheim & Eli Lilly and Company Diabetes Alliance
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Affiliation(s)
- D McGuire
- University of Texas Southwestern Medical Center, Dallas, United States of America
| | - B Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - S E Inzucchi
- Yale University School of Medicine, Section of Endocrinology, New Haven, United States of America
| | - S D Anker
- Charité - Universitätsmedizin, Department of Cardiology (Campus CVK) & BRCT, Berlin, Germany
| | - C Wanner
- Würzburg University Clinic, Würzburg, Germany
| | - S Kaspers
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - M Von Eynatten
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - O.-E Johansen
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - U Elsasser
- Boehringer Ingelheim International GmbH, Biberach, Germany
| | - S Pocock
- London School of Hygiene and Tropical Medicine, Department of Medical Statistics, London, United Kingdom
| | - D Fitchett
- St. Michael's Hospital, Division of Cardiology, University of Toronto, Toronto, Canada
| | - W Jamal
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - S Hantel
- Boehringer Ingelheim International GmbH, Biberach, Germany
| | - S S Lund
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
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Berg D, Wiviott S, Scirica B, Gurmu Y, Mosenzon O, Murphy S, Bhatt D, Leiter L, McGuire D, Wilding J, Johansson P, Langkilde A, Raz I, Braunwald E, Sabatine M. 410Heart failure risk stratification and efficacy of dapagliflozin in patients with type 2 diabetes mellitus. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Patients with type 2 diabetes mellitus (T2DM) are at increased risk of developing heart failure (HF). Treatment with sodium-glucose cotransporter-2 (SGLT2) inhibitors reduces the risk of hospitalization for HF (HHF) in patients with T2DM.
Purpose
To develop and validate a practical, multivariable clinical risk score for HHF in patients with T2DM and assess whether this score can identify high-risk patients with T2DM who have the greatest reduction in risk for HHF with an SGLT2 inhibitor.
Methods
We developed a clinical risk score for centrally-adjudicated HHF using independent clinical risk indicators of HHF in 8212 patients with T2DM in the placebo arm of SAVOR-TIMI 53. Candidate variables were assessed using multivariable Cox regression and independent clinical risk indicators achieving statistical significance of p<0.001 were included in the risk score and given weights proportional to the regression coefficients. We externally validated the score in 8578 patients with T2DM in the placebo arm of DECLARE-TIMI 58. Discrimination was assessed using Harrell's c-index. The relative and absolute risk reductions in HHF with the SGLT2 inhibitor dapagliflozin were assessed by baseline HHF risk.
Results
The 5 independent clinical risk indicators were prior heart failure, atrial fibrillation, coronary artery disease, estimated glomerular filtration rate (eGFR), and urine albumin/creatinine ratio (UACR) (Figure, left). A simple integer-based scheme using these predictors identified a strong >16-fold gradient of HHF risk (p-trend <0.001) in both the derivation and validation cohorts, with c-indices of 0.81 and 0.78, respectively. Whereas relative risk reductions were similar across the risk score (25–34%), absolute risk reductions were greater in those at higher baseline risk (interaction p-value for absolute risk reduction <0.01), with high-risk (2 points) and very high-risk patients (≥3 points) having 1.5% and 2.7% absolute risk reductions in HHF at 4 years with dapagliflozin, translating into NNTs of only 65 and 36, respectively (Figure, right).
Conclusion(s)
Risk stratification using a novel clinical risk score for HHF in patients with T2DM identifies patients at higher risk for HHF who derive greater benefit from treatment with the SGLT2 inhibitor dapagliflozin.
Acknowledgement/Funding
SAVOR-TIMI 53 and DECLARE-TIMI 58 were sponsored by AstraZeneca.
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Affiliation(s)
- D Berg
- Brigham and Womens Hospital, Boston, United States of America
| | - S Wiviott
- Brigham and Womens Hospital, Boston, United States of America
| | - B Scirica
- Brigham and Womens Hospital, Boston, United States of America
| | - Y Gurmu
- Brigham and Womens Hospital, Boston, United States of America
| | - O Mosenzon
- Hadassah University Medical Center, Jerusalem, Israel
| | - S Murphy
- Brigham and Womens Hospital, Boston, United States of America
| | - D Bhatt
- Brigham and Womens Hospital, Boston, United States of America
| | - L Leiter
- St. Michael's Hospital, Toronto, Canada
| | - D McGuire
- University of Texas Southwestern Medical School, Dallas, United States of America
| | - J Wilding
- Aintree University Hospital, Liverpool, United Kingdom
| | | | | | - I Raz
- Hadassah University Medical Center, Jerusalem, Israel
| | - E Braunwald
- Brigham and Womens Hospital, Boston, United States of America
| | - M Sabatine
- Brigham and Womens Hospital, Boston, United States of America
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Boyle E, McHugh SM, Elmallah A, Lynch M, McGuire D, Ahmed Z, Canning C, Colgan MP, O’Neill SM, O’Callaghan A, Martin Z, Madhavan P. Explant of aortic stent grafts following endovascular aneurysm repair. Vascular 2019; 27:487-494. [DOI: 10.1177/1708538119832727] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Failure of endovascular aneurysm repair may require explant of the stent graft in a subset of patients. We sought to assess outcomes in a cohort of patients undergoing explant of endovascular aneurysm repair in both emergency and elective settings. Methods Patients undergoing explant of endovascular aneurysm repair were identified from a prospectively maintained database, with additional information obtained through retrospective analysis of medical records. Results Over a 21-year period, 1997–2018 (May), there were 597 endovascular aneurysm repair procedures performed in our institution for abdominal aortic aneurysm. There were 19 endovascular aneurysm repair explants; five of these were referrals from other vascular centres. The median age was 73 years (range 46–81). The median length of time from insertion to explant was 39.2 months (range 0–153). Indications for elective explant were type Ia endoleak (n = 4), type 1b endoleak (n = 1), type II endoleak with increasing sac size (n = 1), type I/III endoleak (n = 1), type IV endoleak (n = 1), and increasing sac size without evident endoleak (type V, n = 2). The remaining nine cases were emergency procedures, with four patients presenting with rupture post endovascular aneurysm repair, four patients presenting with acute stent thrombosis, of which one also had a type 1a endoleak and one aorto-enteric fistula. There were no mortalities in the elective group and three mortalities in the emergency group (0 vs 33.3%, p = 0.087). Overall 30-day mortality was 15.8% Conclusion Explant of aortic stent grafts can be associated with high mortality and morbidity rates, especially in the emergent setting. Patient and device selection and post-operative surveillance remain vitally important to optimise outcomes post endovascular aneurysm repair.
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Affiliation(s)
- E Boyle
- Department of Vascular Surgery, St. James’s Hospital, Dublin 8, Ireland
| | - SM McHugh
- Department of Vascular Surgery, St. James’s Hospital, Dublin 8, Ireland
| | - A Elmallah
- Faculty of Medicine, Menoufia University, Egypt
| | - M Lynch
- Department of Vascular Surgery, St. James’s Hospital, Dublin 8, Ireland
| | - D McGuire
- Department of Vascular Surgery, St. James’s Hospital, Dublin 8, Ireland
| | - Z Ahmed
- Department of Vascular Surgery, St. James’s Hospital, Dublin 8, Ireland
| | - C Canning
- Department of Vascular Surgery, St. James’s Hospital, Dublin 8, Ireland
| | - MP Colgan
- Department of Vascular Surgery, St. James’s Hospital, Dublin 8, Ireland
| | - SM O’Neill
- Department of Vascular Surgery, St. James’s Hospital, Dublin 8, Ireland
| | - A O’Callaghan
- Department of Vascular Surgery, St. James’s Hospital, Dublin 8, Ireland
| | - Z Martin
- Department of Vascular Surgery, St. James’s Hospital, Dublin 8, Ireland
| | - P Madhavan
- Department of Vascular Surgery, St. James’s Hospital, Dublin 8, Ireland
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McGuire D, Lane N, Segal N, Metyas S, Barthel H, Miller M, Rosen D, Kumagai Y. TPX-100 leads to marked, sustained improvements in subjects with knee osteoarthritis: pre-clinical rationale and results of a controlled clinical trial. Osteoarthritis Cartilage 2018. [DOI: 10.1016/j.joca.2018.02.502] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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8
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Hardy JJ, Mooney SR, Pearson AN, McGuire D, Correa DJ, Simon RP, Meller R. Assessing the accuracy of blood RNA profiles to identify patients with post-concussion syndrome: A pilot study in a military patient population. PLoS One 2017; 12:e0183113. [PMID: 28863142 PMCID: PMC5581162 DOI: 10.1371/journal.pone.0183113] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 07/28/2017] [Indexed: 11/18/2022] Open
Abstract
Mild traumatic brain injury (mTBI) is a complex, neurophysiological condition that can have detrimental outcomes. Yet, to date, no objective method of diagnosis exists. Physical damage to the blood-brain-barrier and normal waste clearance via the lymphatic system may enable the detection of biomarkers of mTBI in peripheral circulation. Here we evaluate the accuracy of whole transcriptome analysis of blood to predict the clinical diagnosis of post-concussion syndrome (PCS) in a military cohort. Sixty patients with clinically diagnosed chronic concussion and controls (no history of concussion) were recruited (retrospective study design). Male patients (46) were split into a training set comprised of 20 long-term concussed (> 6 months and symptomatic) and 12 controls (no documented history of concussion). Models were validated in a testing set (control = 9, concussed = 5). RNA_Seq libraries were prepared from whole blood samples for sequencing using a SOLiD5500XL sequencer and aligned to hg19 reference genome. Patterns of differential exon expression were used for diagnostic modeling using support vector machine classification, and then validated in a second patient cohort. The accuracy of RNA profiles to predict the clinical diagnosis of post-concussion syndrome patients from controls was 86% (sensitivity 80%; specificity 89%). In addition, RNA profiles reveal duration of concussion. This pilot study shows the potential utility of whole transcriptome analysis to establish the clinical diagnosis of chronic concussion syndrome.
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Affiliation(s)
- Jimmaline J. Hardy
- Neuroscience Institute, Morehouse School of Medicine, Atlanta, Georgia, United States of America
| | - Scott. R. Mooney
- Neuroscience & Rehabilitation Center, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia, United States of America
| | - Andrea. N. Pearson
- Neuroscience Institute, Morehouse School of Medicine, Atlanta, Georgia, United States of America
| | - Dawn McGuire
- Department of Medicine, Morehouse School of Medicine, Atlanta, Georgia, United States of America
| | - Daniel. J. Correa
- Neuroscience & Rehabilitation Center, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia, United States of America
| | - Roger P. Simon
- Neuroscience Institute, Morehouse School of Medicine, Atlanta, Georgia, United States of America
- Department of Medicine, Morehouse School of Medicine, Atlanta, Georgia, United States of America
| | - Robert Meller
- Neuroscience Institute, Morehouse School of Medicine, Atlanta, Georgia, United States of America
- * E-mail:
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9
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Meller R, Pearson AN, Hardy JJ, Hall CL, McGuire D, Frankel MR, Simon RP. Blood transcriptome changes after stroke in an African American population. Ann Clin Transl Neurol 2016; 3:70-81. [PMID: 26900583 PMCID: PMC4748310 DOI: 10.1002/acn3.272] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 10/07/2015] [Accepted: 10/28/2015] [Indexed: 12/20/2022] Open
Abstract
Objective Molecular diagnostic medicine holds much promise to change point of care treatment. An area where additional diagnostic tools are needed is in acute stroke care, to assist in diagnosis and prognosis. Previous studies using microarray‐based gene expression analysis of peripheral blood following stroke suggests this approach may be effective. Next‐generation sequencing (NGS) approaches have expanded genomic analysis and are not limited to previously identified genes on a microarray chip. Here, we report on a pilot NGS study to identify gene expression and exon expression patterns for the prediction of stroke diagnosis and prognosis. Methods We recruited 28 stroke patients and 28 age‐ and sex‐matched hypertensive controls. RNA was extracted from 3 mL blood samples, and RNA‐Seq libraries were assembled and sequenced. Results Bioinformatical analysis of the aligned RNA data reveal exonic (30%), intronic (36%), and novel RNA components (not currently annotated: 33%). We focused our study on patients with confirmed middle cerebral artery occlusion ischemic stroke (n = 17). On the basis of our observation of differential splicing of gene transcripts, we used all exonic RNA expression rather than gene expression (combined exons) to build prediction models using support vector machine algorithms. Based on model building, these models have a high predicted accuracy rate >90% (spec. 88% sen. 92%). We further stratified outcome based on the improvement in NIHss scores at discharge; based on model building we observe a predicted 100% accuracy rate. Interpretation NGS‐based exon expression analysis approaches have a high potential for patient diagnosis and outcome prediction, with clear utility to aid in clinical patient care.
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Affiliation(s)
- Robert Meller
- Translational Stroke Program Neuroscience Institute Morehouse School of Medicine Atlanta Georgia
| | - Andrea N Pearson
- Translational Stroke Program Neuroscience Institute Morehouse School of Medicine Atlanta Georgia
| | - Jimmaline J Hardy
- Translational Stroke Program Neuroscience Institute Morehouse School of Medicine Atlanta Georgia
| | - Casey L Hall
- Grady Memorial Hospital Atlanta Georgia; Department of Neurology Emory University Atlanta Georgia
| | - Dawn McGuire
- Translational Stroke Program Neuroscience Institute Morehouse School of Medicine Atlanta Georgia
| | - Michael R Frankel
- Grady Memorial Hospital Atlanta Georgia; Department of Neurology Emory University Atlanta Georgia
| | - Roger P Simon
- Translational Stroke Program Neuroscience Institute Morehouse School of Medicine Atlanta Georgia; Grady Memorial Hospital Atlanta Georgia
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Finkel R, Day J, Chiriboga C, Vasjar J, Cook D, Watson K, Paulose S, McMillian L, Cruz R, Montes J, Vivo DD, Yamashita M, McGuire D, Alexander K, Norris D, Bennett C, Bishop K. G.O.17. Neuromuscul Disord 2014. [DOI: 10.1016/j.nmd.2014.06.416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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11
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Darras B, Chiriboga C, Swoboda K, Iannaccone S, Montes J, Castro D, Holuba N, Raush N, Visyak N, Dunaway S, Trussell D, Pasternak A, Neilson L, Vivo DD, McGuire D, Norris D, Alexander K, Bennett C, Bishop K. G.O.18. Neuromuscul Disord 2014. [DOI: 10.1016/j.nmd.2014.06.417] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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12
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Gogate PR, Mededovic-Thagard S, McGuire D, Chapas G, Blackmon J, Cathey R. Hybrid reactor based on combined cavitation and ozonation: from concept to practical reality. Ultrason Sonochem 2014; 21:590-8. [PMID: 24048074 DOI: 10.1016/j.ultsonch.2013.08.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 08/24/2013] [Accepted: 08/25/2013] [Indexed: 05/15/2023]
Abstract
The present work gives an in depth discussion related to the development of a hybrid advanced oxidation reactor, which can be effectively used for the treatment of various types of water. The reactor is based on the principle of intensifying degradation/disinfection using a combination of hydrodynamic cavitation, acoustic cavitation, ozone injection and electrochemical oxidation/precipitation. Theoretical studies have been presented to highlight the uniform distribution of the cavitational activity and enhanced generation of hydroxyl radicals in the cavitation zone, as well as higher turbulence in the main reactor zone. The combination of these different oxidation technologies have been shown to result in enhanced water treatment ability, which can be attributed to the enhanced generation of hydroxyl radicals, enhanced contact of ozone and contaminants, and the elimination of mass transfer resistances during electrochemical oxidation/precipitation. Compared to the use of individual approaches, the hybrid reactor is expected to intensify the treatment process by 5-20 times, depending on the application in question, which can be confirmed based on the literature illustrations. Also, the use of Ozonix® has been successfully proven while processing recycled fluids at commercial sites on over 750 oil and natural gas wells during hydraulic operations around the United States. The superiority of the hybrid process over conventional chemical treatments in terms of bacteria and scale reduction as well as increased water flowability and better chemical compatibility, which is a key requirement for oil and gas applications, has been established.
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Affiliation(s)
- P R Gogate
- Chem. Eng. Dept., Institute of Chemical Technology, Mumbai 400 019, India.
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13
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Garrett SL, Sawyer P, Kennedy RE, McGuire D, Simon RP, Strothers HS, Allman RM. Racial and sex differences in associations between activities of daily living and cognition in community-dwelling older adults. J Am Geriatr Soc 2014; 61:2174-2180. [PMID: 24479147 DOI: 10.1111/jgs.12543] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine the association between function measured according to activities of daily living (ADLs), instrumental activ1ities of daily living (IADLs), and cognition assessed according to Mini-Mental State Examination (MMSE) scores of older African-American and non-Hispanic white community-dwelling men and women. DESIGN Cross-sectional study assessing associations between self-reported ADL and IADL difficulty and MMSE scores for race- and sex-specific groups. SETTING Homes of community-dwelling older adults. PARTICIPANTS A random sample of 974 African-American and non-Hispanic white Medicare beneficiaries aged 65 and older living in west-central Alabama and participating in the University of Alabama at Birmingham Study of Aging, excluding those with reported diagnoses of dementia or with missing data. MEASUREMENTS Function, based on self-reported difficulty in performing ADLs and IADLs, and cognition, using the MMSE. Multivariable linear regression models were used to test the association between function and cognition in race- and sex-specific groups after adjusting for covariates. RESULTS Mini-Mental State Examination scores were modestly correlated with ADL and IADL difficulty in all four race- and sex-specific groups, with Pearson correlation coefficients ranging from −0.189 for non-Hispanic white women to −0.429 for African-American men. Correlations between MMSE and ADL or IADL difficulty in any of the race- and sex-specific groups were no longer significant after controlling for sociodemographic factors and comorbidities. CONCLUSION Mini-Mental State Examination was not significantly associated with functional difficulty in older African-American and non-Hispanic white men and women after adjusting for sociodemographic factors and comorbidities, suggesting a mediating role in the relationship between cognition and function.
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Affiliation(s)
- Stephanie L Garrett
- Department of Family Medicine, National Center for Primary Care, Morehouse School of Medicine, Atlanta, Georgia
| | - Patricia Sawyer
- Comprehensive Center for Healthy Aging, Gerontology Education Program, University of Alabama at Birmingham, Birmingham, Alabama.,Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama
| | - Richard E Kennedy
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama
| | - Dawn McGuire
- Neuroscience Institute, Morehouse School of Medicine, Atlanta, Georgia
| | - Roger P Simon
- Translational Programs in Stroke, Morehouse School of Medicine, Atlanta, Georgia.,Department of Medicine (Neurology), Morehouse School of Medicine, Atlanta, Georgia.,Department of Neurobiology, Morehouse School of Medicine, Atlanta, Georgia
| | - Harry S Strothers
- Department of Family Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Richard M Allman
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama.,Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Birmingham, Alabama.,Comprehensive Center for Healthy Aging, Deep South Resource Center for Minority Aging Research, University of Alabama at Birmingham, Birmingham, Alabama.,Southeast Center of Excellence in Geriatric Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Ellis DJ, Dissanayake S, McGuire D, Charapata SG, Staats PS, Wallace MS, Grove GW, Vercruysse P. Continuous Intrathecal Infusion of Ziconotide for Treatment of Chronic Malignant and Nonmalignant Pain Over 12 Months: A Prospective, Open-label Study. Neuromodulation 2013; 11:40-9. [PMID: 22150990 DOI: 10.1111/j.1525-1403.2007.00141.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives. This study aims to assess the safety and efficacy of long-term intrathecal (IT) ziconotide infusion. Materials and Methods. In this prospective study, 155 patients with severe chronic pain (48 with malignant pain, 107 with nonmalignant pain) who had been responsive to short-term IT ziconotide in a double-blind, placebo-controlled study received long-term, open-label IT ziconotide monotherapy. Efficacy assessments included the mean percentage change on the visual analog scale of pain intensity from baseline in the study of origin; safety was monitored by adverse event (AE) reports, periodic laboratory tests, and vital sign measurements. Results. At the last available observation, the visual analog scale of pain intensity scores had decreased by a mean of 36.9% from baseline in the short-term trial (N = 144; 95% CI: 30.1-43.7%; p < 0.0001). The mean IT ziconotide dose remained stable over 12 months in the 31 patients who participated in the study for ≥ one year. Ziconotide-related AEs were reported in 147 out of 155 patients (94.8%); 39.4% of patients discontinued treatment because of AEs, the majority of which were considered ziconotide related. Conclusions. Ziconotide IT monotherapy provided patients with analgesia for 12 months in this open-label study, with an acceptable benefit/risk profile and no evidence of tolerance.
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Affiliation(s)
- David J Ellis
- ARYx Therapeutics, Fremont, CA, USA; Medicines and Healthcare Products Regulatory Agency, London, UK; California Pacific Medical Center, San Francisco, CA, USA; Pain Management Associates of Kansas City, Kansas City, MO, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Center for Pain Medicine, University of California, San Diego, La Jolla, CA, USA; Orthopedic and Sports Medicine Center, Elkhart, IN, USA; and Brugge Multidisciplinary Pain Unit, Brugge, Belgium
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Mandava P, Murthy SB, Munoz M, McGuire D, Simon RP, Alexandrov AV, Albright KC, Boehme AK, Martin-Schild S, Martini S, Kent TA. Explicit consideration of baseline factors to assess recombinant tissue-type plasminogen activator response with respect to race and sex. Stroke 2013; 44:1525-31. [PMID: 23674524 DOI: 10.1161/strokeaha.113.001116] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Sex and race reportedly influence outcome after recombinant tissue-type plasminogen activator (rtPA). It is, however, unclear whether baseline imbalances (eg, stroke severity) or lack of response to thrombolysis is responsible. We applied balancing methods to test the hypothesis that race and sex influence outcome after rtPA independent of baseline conditions. METHODS We mapped group outcomes from the National Institute of Neurological Disorders and Stroke (NINDS) dataset based on race and sex onto a surrogate-control function to assess differences from expected outcomes at their respective National Institutes of Health Stroke Scale and age. Outcomes were also compared for subjects matched individually on key baseline factors using NINDS and 2 recent datasets from southeastern United States. RESULTS At similar National Institutes of Health Stroke Scale and age, 90-day good outcomes (modified Rankin Score, 0-2) in NINDS were similarly improved after rtPA for white men and women. There was a strong trend for improvement in black men. Conversely, black women treated with rtPA showed response rates no different from the controls. After baseline matching, there were nonsignificant trends in outcomes except for significantly fewer good outcomes in black versus matched white women (37% versus 63%; P=0.027). Pooling the 3 datasets showed a similar trend for poorer short-term outcome for black women (P=0.054; modified Rankin Score, 0-1). CONCLUSIONS Matching for key baseline factors indicated that race and sex influence outcome most strikingly in black women who demonstrated poorest outcomes after rtPA. This finding supports the hypothesis that poor response to rtPA, rather than differences in baseline conditions, contributes to the worse outcome. This finding requires prospective confirmation.
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Affiliation(s)
- Pitchaiah Mandava
- Stroke Outcomes Laboratory, Department of Neurology, Baylor College of Medicine, The Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd (127), Houston, TX 77030, USA.
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Wermeling D, Drass M, Ellis D, Mayo M, McGuire D, O'Connell D, Hale V, Chao S. Pharmacokinetics and Pharmacodynamics of Intrathecal Ziconotide in Chronic Pain Patients. J Clin Pharmacol 2013. [DOI: 10.1177/0091270003253349] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Mandava P, Martini S, Albright KC, Boehme AK, Martin-Schild S, Alexandrov AV, Simon RP, McGuire D, Kent TA. Abstract TP62: Outcomes After tPA in African American Women with Explicit Consideration of Baseline Factors. Stroke 2013. [DOI: 10.1161/str.44.suppl_1.atp62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
African American (AA) women have been reported to have higher mortality after stroke. Our prior analysis of the NINDS dataset also showed poorer outcomes after tPA for AA compared to Caucasian (C) females. Small numbers of AA patients available in a well characterized dataset and large differences in baseline factors hamper definitive conclusions about race-based outcomes. We developed analytical techniques for small samples that explicitly consider baseline factors rather than adjust or control for them. We applied these techniques to two stroke datasets and analyzed them separately and together with NINDS.
Methods:
pPREDICTS uses the placebo arms of all eligible stroke RCTs to generate a pseudo-control outcome model. The novel feature is generation of multi-dimensional statistical intervals to compare whether an individual trial’s outcome differed from this pooled sample at the trial’s specific baseline NIHSS and age. pPAIRS performs post-hoc Euclidean matching of subjects based on chosen factors and excludes outliers when no close match is found, generating a more homogenous population. We applied these techniques to assess outcomes of tpa-treated females from the NINDS, Tulane, and University of Alabama-Birmingham datasets. Matching factors were baseline NIHSS, age, glucose, race and stroke subtype. Outcomes were mRS 0-1, 0-2 and mortality at discharge or 90 days.
Results:
Pooled results from individual sites are reported here. Comparison of outcomes from each site with the pPREDICTS model did not show better outcomes for the newer datasets compared to NINDS. mRS 0-2 for tPA-treated AA females was near the p=.05 threshold for poorer outcomes compared to pooled controls. After outlier exclusion, 80 matched AA and C females were found by pPAIRS. After matching, median baseline NIHSS were similar: 12.5 for AA’s and 11.5 for C (p = 0.64). Final mRS 0-1 and mRS 0-2 for AA females were lower: 22.5% and 30% vs. 40% (p = 0.03) and 46.3% for C (p = 0.05). Mortality was 10% in AA and 7% in C (p=0.6).
Conclusion:
We confirmed in this larger pooled sample that AA females have a poorer functional outcome following tPA after baseline matching. Factors associated with these poor outcomes are being assessed and will be presented. A prospective study is warranted.
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McGuire D. Poems from The Aphasia Cafe. Neurology 2012. [DOI: 10.1212/wnl.0b013e318278b5f7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Mathur VS, Lindberg J, Germain M, Block G, Tumlin J, Smith M, Grewal M, McGuire D. A longitudinal study of uremic pruritus in hemodialysis patients. Clin J Am Soc Nephrol 2010; 5:1410-9. [PMID: 20558560 DOI: 10.2215/cjn.00100110] [Citation(s) in RCA: 169] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Although uremic pruritus (UP) is a highly prevalent complication of chronic kidney disease, it remains poorly characterized. There have been no longitudinal studies of natural history, and no health-related quality of life (HR-QOL) instruments have been developed for UP. The objectives of this study were to describe the natural history of UP, to compare rating scales of itching intensity, and to assess usefulness and validity of HR-QOL instruments for UP. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The intensity, severity, and effects of pathologic itching on HR-QOL were assessed prospectively in 103 patients with UP on chronic hemodialysis. Outcome measures were obtained at scheduled intervals over 3.5 months. RESULTS Itching daily or nearly daily was reported by 84% of patients and had been ongoing for >1 year in 59%. In 83%, pruritus involved large, nondermatomal areas with striking bilateral symmetry. Two thirds of the patients were using medications such as antihistamines, steroids, and various emollients without satisfactory relief of itching. Statistically significant associations were found among itching intensity, severity, and HR-QOL measures in domains such as mood, social relations, and sleep. Among patients with moderate-to-severe UP, changes in itching intensity of 20% or greater were associated with significant reductions in HR-QOL measures. CONCLUSIONS This first longitudinal study of UP describes key features of UP and its effect on HR-QOL. The assessment instruments we have developed are easily used, are responsive to changes in UP intensity, and should facilitate clinical evaluation and research to meet the needs of afflicted patients.
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Silverberg GD, Mayo M, Saul T, Fellmann J, Carvalho J, McGuire D. Continuous CSF drainage in AD: results of a double-blind, randomized, placebo-controlled study. Neurology 2008; 71:202-9. [PMID: 18525029 DOI: 10.1212/01.wnl.0000316197.04157.6f] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Alzheimer disease (AD) has been associated with abnormal cerebral clearance of macromolecules, such as amyloid and microtubule-associated-protein tau (MAP-tau). We hypothesized that improving clearance of macromolecules from the CNS might slow the progression of dementia. OBJECTIVE This prospective, randomized, double-blinded, placebo-controlled trial evaluated the safety and effectiveness of a surgically implanted shunt in subjects with probable AD. METHODS A total of 215 subjects with probable AD by National Institute of Neurological Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria received either a low-flow ventriculoperitoneal shunt or a sham (occluded) shunt for 9 months. Longitudinal CSF sampling was performed in both active and control subjects. Primary outcome measures were the Mattis Dementia Rating Scale and the Global Deterioration Scale. CSF Abeta((1-42)) and MAP-tau also were assayed. RESULTS After a planned interim analysis, the study was halted for futility. Using the intent-to-treat population, no between-group differences were observed in the primary outcome measures. The surgical procedure and device were associated with 12 CNS infections, some temporally associated with CSF sampling. All were treated successfully. CONCLUSIONS We found no benefit to low-flow CSF shunting in subjects with mild to severe Alzheimer disease. CSF infections, while treatable, occurred more frequently than expected, in some cases likely related to CSF sampling.
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Affiliation(s)
- G D Silverberg
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA.
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Saul T, McGuire D, Mayo M, Fellmann J, Carvalho J, Silverberg GD, Williams J. Shunting in AD increases ventricular CSF protein levels. Cerebrospinal Fluid Res 2007. [DOI: 10.1186/1743-8454-4-s1-s5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Saul T, McGuire D, Mayo M, Fellmann J, Carvalho J, Silverberg GD, Williams J. Shunting in AD slows progression of the dementia. Cerebrospinal Fluid Res 2007. [DOI: 10.1186/1743-8454-4-s1-s42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Silverberg G, Mayo M, Saul T, Fellmann J, McGuire D. Elevated cerebrospinal fluid pressure in patients with Alzheimer's disease. Cerebrospinal Fluid Res 2006; 3:7. [PMID: 16737542 PMCID: PMC1538629 DOI: 10.1186/1743-8454-3-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Accepted: 05/31/2006] [Indexed: 11/23/2022] Open
Abstract
Background Abnormalities in cerebrospinal fluid (CSF) production and turnover, seen in normal pressure hydrocephalus (NPH) and in Alzheimer's disease (AD), may be an important cause of amyloid retention in the brain and may relate the two diseases. There is a high incidence of AD pathology in patients being shunted for NPH, the AD-NPH syndrome. We now report elevated CSF pressure (CSFP), consistent with very early hydrocephalus, in a subset of AD patients enrolled in a clinical trial of chronic low-flow CSF drainage. Our objective was to determine the frequency of elevated CSFP in subjects meeting National Institutes of Neurological and Communicative Diseases and Stroke – Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) criteria for AD, excluding those with signs of concomitant NPH. Methods AD subjects by NINCDS-ADRDA criteria (n = 222), were screened by history, neurological examination, and radiographic imaging to exclude those with clinical or radiographic signs of NPH. As part of this exclusion process, opening CSFP was measured supine under general anesthesia during device implantation surgery at a controlled pCO2 of 40 Torr (40 mmHg). Results Of the 222 AD subjects 181 had pressure measurements recorded. Seven subjects (3.9%) enrolled in the study had CSFP of 220 mmH20 or greater, mean 249 ± 20 mmH20 which was significantly higher than 103 ± 47 mmH2O for the AD-only group. AD-NPH patients were significantly younger and significantly less demented on the Mattis Dementia Rating Scale (MDRS). Conclusion Of the AD subjects who were carefully screened to exclude those with clinical NPH, 4% had elevated CSFP. These subjects were presumed to have the AD-NPH syndrome and were withdrawn from the remainder of the study.
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Affiliation(s)
- Gerald Silverberg
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Martha Mayo
- Genitope Corp, 525 Penobscot Drive, Redwood City, CA,94063, USA
| | - Thomas Saul
- Turning Point Engineering, PO box 372 Moss Beach CA, 94038, USA
| | - Jere Fellmann
- Acologix Inc, 3960 Point Eden Way, Hayward, CA 94545, USA
| | - Dawn McGuire
- Avigen Inc, 1301 Harbor Bay Parkway, Alameda CA 94502, USA
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Wallace MS, Charapata SG, Fisher R, Byas-Smith M, Staats PS, Mayo M, McGuire D, Ellis D. Intrathecal Ziconotide in the Treatment of Chronic Nonmalignant Pain: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Neuromodulation 2006; 9:75-86. [DOI: 10.1111/j.1525-1403.2006.00055.x] [Citation(s) in RCA: 166] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Silverberg GD, Mayo M, Saul T, Carvalho J, McGuire D. Novel ventriculo-peritoneal shunt in Alzheimer's disease cerebrospinal fluid biomarkers. Expert Rev Neurother 2006; 4:97-107. [PMID: 15853620 DOI: 10.1586/14737175.4.1.97] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Alzheimer's disease is an age-related dementia and its incidence is rising in developed countries as the population ages. Amyloid plaques and tau-rich neurofibrillary tangles are pathologic hallmarks of the disease. Treatment is symptomatic, consisting of compounds that block enzymatic acetylcholine degradation (acetylcholinesterase inhibitors). Cognitive benefits of the four approved antidementia drugs are typically modest and limited in duration. While Alzheimer's disease is undoubtedly multifactorial in cause, advancing age is the most important risk factor. Any robust theory of pathogenesis must account for the profound influence of age on the emergence of Alzheimer's disease. There is evidence that senescent changes in cerebrospinal fluid production, circulation, turnover and clearance of amyloid beta-peptides may be a key factor in the onset and progression of Alzheimer's disease. The effect of increasing cerebrospinal fluid circulation and turnover in Alzheimer's disease patients by implanting a novel, low-flow drainage system (COGNIshunt) has been studied and promising trends in cognitive stabilization and improvement in cerebrospinal fluid biomarkers have been found.
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Affiliation(s)
- Gerald D Silverberg
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA.
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Praticò D, Yao Y, Rokach J, Mayo M, Silverberg GG, McGuire D. Reduction of brain lipid peroxidation by CSF drainage in Alzheimer's disease patients. J Alzheimers Dis 2004; 6:385-9; discussion 443-9. [PMID: 15345808 DOI: 10.3233/jad-2004-6405] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Alzheimer's disease (AD) is associated with an increase in cerebrospinal fluid (CSF) levels of the isoprostane 8,12-iso-iPF2alpha-VI, a specific marker of in vivo lipid peroxidation. Poor cerebral clearance of end products of oxidative reactions via CSF circulation may contribute to and sustain ongoing stress. CSF drainage via a low-flow ventriculoperitoneal (VP) shunt may improve removal of these products, reducing oxidative stress. We quantified this biomarker in patients with AD undergoing to VP shunt placement at baseline and after one-year period. CSF sampling occurred at baseline and quarterly visits for one year. Levels of this isoprostane were determined simultaneously at the end of the study by gas chromatography negative ion chemical ionization mass spectrometry. Over one-year, CSF 8,12-iso-iPF2alpha-VI levels consistently decreased versus baseline (51% of initial level), while CSF protein, glucose, cell count and IgG concentrations remained within normal limits. This finding supports the hypothesis that improving CSF drainage enhances extra-cellular clearance of end products of oxidative reactions and lowers brain lipid peroxidation.
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Affiliation(s)
- Domenico Praticò
- Department of Pharmacology, The Center for Experimental Therapeutics, University of Pennsylvania, School of Medicine, Philadelphia 19104, USA.
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Staats PS, Yearwood T, Charapata SG, Presley RW, Wallace MS, Byas-Smith M, Fisher R, Bryce DA, Mangieri EA, Luther RR, Mayo M, McGuire D, Ellis D. Intrathecal ziconotide in the treatment of refractory pain in patients with cancer or AIDS: a randomized controlled trial. JAMA 2004; 291:63-70. [PMID: 14709577 DOI: 10.1001/jama.291.1.63] [Citation(s) in RCA: 378] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Ziconotide (formerly SNX-111) selectively blocks N-type voltage-sensitive calcium channels and may be effective in patients with pain that is refractory to opioid therapy or those with intolerable opioid-related adverse effects. OBJECTIVE To assess the safety and efficacy of intrathecal ziconotide in patients with pain that is refractory to conventional treatment. DESIGN, SETTING, AND PATIENTS Double-blind, placebo-controlled, randomized trial conducted from March 12, 1996, to July 11, 1998, at 32 study centers in the United States, Australia, and the Netherlands. Patients were 111 individuals ages 24 to 85 years with cancer or AIDS and a mean Visual Analog Scale of Pain Intensity (VASPI) score of 50 mm or greater. Patients were randomly assigned in a 2:1 ratio to receive ziconotide or placebo treatment. INTERVENTIONS Intrathecal ziconotide was titrated over 5 to 6 days, followed by a 5-day maintenance phase for responders and crossover of nonresponders to the opposite treatment group. MAIN OUTCOME MEASURE Mean percentage change in VASPI score from baseline to the end of the initial titration period. RESULTS Of the evaluable population, 67 (98.5%) of 68 patients receiving ziconotide and 38 (95%) of 40 patients receiving placebo were taking opioids at baseline (median morphine equivalent dosage of 300 mg/d for the ziconotide group and 600 mg/d for the placebo group; P =.63, based on mean values), and 36 had used intrathecal morphine. Mean (SD) VASPI scores were 73.6 (1.8) mm in the ziconotide group and 77.9 (2.3) mm in the placebo group (P =.18). Mean VASPI scores improved 53.1% (95% confidence interval [CI], 44.0%-62.2%) in the ziconotide group and 18.1% (95% CI, 4.8%-31.4%) in the placebo group (P<.001), with no loss of efficacy of ziconotide in the maintenance phase. Pain relief was moderate to complete in 52.9% of patients in the ziconotide group compared with 17.5% in the placebo group (P<.001). Five patients receiving ziconotide achieved complete pain relief, and 50.0% of patients receiving ziconotide responded to therapy compared with 17.5% of those receiving placebo (P =.001). CONCLUSION Intrathecal ziconotide provided clinically and statistically significant analgesia in patients with pain from cancer or AIDS.
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Affiliation(s)
- Peter S Staats
- Division of Pain Medicine, Johns Hopkins University School of Medicine, Baltimore, Md 21205, USA.
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Silverberg GD, Mayo M, Saul T, Rubenstein E, McGuire D. Alzheimer's disease, normal-pressure hydrocephalus, and senescent changes in CSF circulatory physiology: a hypothesis. Lancet Neurol 2003; 2:506-11. [PMID: 12878439 DOI: 10.1016/s1474-4422(03)00487-3] [Citation(s) in RCA: 274] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
There is evidence that production and turnover of CSF help to clear toxic molecules such as amyloid-beta peptide (Abeta) from the interstitial-fluid space of the brain to the bloodstream. Two changes in CSF circulatory physiology have been noted as part of ageing: first, a trend towards lower CSF production, hence a decrease in CSF turnover; and second, greater resistance to CSF outflow. Our hypothesis is that, all else being equal, the initially dominant physiological change determines whether CSF circulatory failure manifests as Alzheimer's disease (AD) or as normal-pressure hydrocephalus (NPH). If CSF production failure predominates, AD develops. However, if resistance to CSF outflow predominates, NPH results. Once either disease process takes hold, the risk of the other disorder may rise. In AD, increased deposition of Abeta in the meninges leads to greater resistance to CSF outflow. In NPH, raised CSF pressure causes lower CSF production and less clearance of Abeta. The disorders may ultimately converge in vulnerable individuals, resulting in a hybrid as has been observed in several clinical series. We postulate a new nosological entity of CSF circulatory failure, with features of AD and NPH. NPH-AD may cover an important subset of patients who carry the diagnosis of either AD or NPH.
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Wermeling D, Drass M, Ellis D, Mayo M, McGuire D, O'Connell D, Hale V, Chao S. Pharmacokinetics and Pharmacodynamics of Intrathecal Ziconotide in Chronic Pain Patients. J Clin Pharmacol 2003. [DOI: 10.1177/0091270003043006008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Royal W, Dupont B, McGuire D, Chang L, Goodkin K, Ernst T, Post MJ, Fish D, Pailloux G, Poncelet H, Concha M, Apuzzo L, Singer E. Topotecan in the treatment of acquired immunodeficiency syndrome-related progressive multifocal leukoencephalopathy. J Neurovirol 2003; 9:411-9. [PMID: 12775425 DOI: 10.1080/13550280390201740] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Progressive multifocal leukoencephalopathy (PML) affects about 1 in 20 individuals with the acquired immunodeficiency syndrome (AIDS) and has been associated with poor survival. This report describes the results of a phase II clinical trial using the drug topotecan, a semisynthetic analogue of camptothecan, administered to a cohort of subjects with AIDS-related PML. Data were evaluated on 11 of 12 subjects enrolled in the study. Three responded to therapy. Additionally, one patient was treated off-protocol and showed a response to treatment. Progression occurred after the first course; however, a partial response was noted after five courses. One study patient died from accidental overdose of topotecan. Overall, responders had higher pretreatment Karnofsky and lower Kurtzke expanded disability status scale scores than nonresponders. The most frequent toxicities were hematologic (anemia, neutropenia, and thrombocytopenia). Five patients had dose delays; all delays were due to hematologic adverse events. This study demonstrates that topotecan treatment may be associated with decreased lesion size and prolonged survival from the infection. Because of the small number of subjects in the study, further studies are required to evaluate the efficacy of topotecan in treating this disease.
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Affiliation(s)
- W Royal
- Neuroscience Institute, Morehouse School of Medicine, Atlanta, Georgia 30310-1495, USA.
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Wermeling D, Drass M, Ellis D, Mayo M, McGuire D, O'Connell D, Hale V, Chao S. Pharmacokinetics and pharmacodynamics of intrathecal ziconotide in chronic pain patients. J Clin Pharmacol 2003; 43:624-36. [PMID: 12817525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
The pharmacokinetics and pharmacodynamics of ziconotide were assessed over a 48-hour period following intrathecal (i.t.) administration (1, 5, 7.5, or 10 micrograms) to 22 patients with chronic, nonmalignant pain. Plasma and cerebrospinal fluid (CSF) samples were obtained over a 24-hour period. Analgesic efficacy was monitored using Visual Analog Scale of Pain Intensity (VASPI) and Category Pain Relief Scores (CPRS) measurements. Pharmacokinetic (PK) parameters were calculated by noncompartmental methods. Plasma ziconotide data were insufficient for PK calculations. In CSF, the median half-life of ziconotide was 4.5 hours. The median CSF clearance and volume of distribution were 0.26 mL/min and 99 mL, respectively. CSF pharmacokinetics of ziconotide were linear, based on cumulative exposure and peak CSF concentrations. A dose-related analgesia was observed. Pharmacokinetic-pharmacodynamic efficacy and safety analyses showed that higher CSF ziconotide concentrations were generally associated with analgesia and increased incidence of nervous system adverse events following a 1-hour i.t. infusion.
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Affiliation(s)
- Daniel Wermeling
- University of Kentucky Medical Center, Pain Treatment Center, Lexington, Kentucky, USA
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Royal W, Dupont B, McGuire D, Chang L, Goodkin K, Ernst T, Post MJ, Fish D, Pailloux G, Poncelet H, Concha M, Apuzzo L, Singer E. Topotecan in the Treatment of Acquired Immunodeficiency Syndrome-Related Progressive Multifocal Leukoencephalopathy. J Neurovirol 2003. [DOI: 10.1080/713831540] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Silverberg GD, Levinthal E, Sullivan EV, Bloch DA, Chang SD, Leverenz J, Flitman S, Winn R, Marciano F, Saul T, Huhn S, Mayo M, McGuire D. Assessment of low-flow CSF drainage as a treatment for AD: results of a randomized pilot study. Neurology 2002; 59:1139-45. [PMID: 12391340 DOI: 10.1212/01.wnl.0000031794.42077.a1] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE This prospective, randomized, controlled study was designed to investigate the safety, feasibility, and preliminary efficacy of long-term CSF drainage via a low-flow ventriculoperitoneal shunt in subjects suffering from AD. METHODS Twenty-nine subjects selected for probable AD (National Institute of Neurological and Communicative Diseases and Stroke-Alzheimer's Disease and Related Dementias Association criteria) were screened to exclude normal pressure hydrocephalus or other etiologies of dementia and randomized to treatment (shunt) or no treatment groups. The study endpoint was the comparison of group performance on psychometric testing at quarterly intervals for 1 year. Shunted subjects had CSF withdrawn for MAP-tau and Abeta((1-42)) assays at the same time intervals. RESULTS There was no mortality from the surgical procedure, and no patient sustained a subdural hematoma. Five notable postoperative adverse events, which resolved without permanent neurologic deficit, were reported in the shunt group. Group mean Mattis Dementia Rating Scale total scores showed little change over the year in the shunt-treatment group, in contrast to a decline in the control group (p = 0.06). Mini-Mental State Examination mean scores supported a trend in favor of shunt treatment (p = 0.1). There was a concomitant decrease in ventricular CSF concentrations of AD biomarkers MAP-tau and Abeta((1-42)). CONCLUSIONS The surgical procedure and the device are reasonably safe. Adverse events were consistent with shunt procedures for hydrocephalus in this older population. The endpoint data show a trend in favor of the treated group. A larger, randomized, double-blinded, controlled, clinical trial is underway.
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Affiliation(s)
- G D Silverberg
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA.
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Yang X, Price JM, Mack JA, Morgan CG, Rogaski CA, McGuire D, Kim EH, Wodtke AM. Stimulated emission pumping studies of energy transfer in highly vibrationally excited molecules. ACTA ACUST UNITED AC 2002. [DOI: 10.1021/j100118a005] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
OBJECTIVE To determine changes in CD14/CD69 cells of HIV seropositive patients with HIV-1 associated dementia (HAD) on highly active antiretroviral therapy (HAART) and to determine the effect of soluble factors from cultured monocyte/macrophage (M/M phi) on neural cell functional proteins. DESIGN AND METHODS Whole blood from patients with HAD, HIV seronegative subjects, and HIV seropositive subjects with no dementia (HIV-ND) was analyzed for CD14/CD69 cells using flow cytometry. M/M phi were isolated and cultured, and supernatants tested for neurotoxicity. Modulation of neural cell proteins and mitogen-activated protein kinases in response to supernatant exposure was examined by Western blot. RESULTS CD14/CD69 levels from HAART-treated HAD subjects were significantly elevated over those from HIV-ND subjects and controls. However, levels were significantly lower than those reported in similarly selected HAD subjects tested prior to the HAART era. Treatment of neural cells with M/M phi-derived culture supernatants from HAART-treated HAD subjects was not associated with cell death, but resulted in a trend towards lower activation of the JNK, AKT, and ERK kinases, decreased expression of SNAP-25, and increased expression of neurofilament light than was observed after treatment with HIV-ND M/M phi supernatants. CONCLUSIONS The clinical phenotype of HAD appears to be evolving from a subacute dementing disease to a more protracted disorder. Decreased CD14/CD69 levels may reflect changes in some aspects of the pathophysiology of brain injury in the era of HAART. Changes in neural cell signaling, structural and functional proteins may represent more subtle neurotoxicity, manifested in cell dysfunction rather than frank cell death.
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Affiliation(s)
- Leonard Kusdra
- Department of Laboratory Medicine, Veterans Affairs Medical Center, University of California, San Francisco, California 94121, USA
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Conneely J, McGuire D, Fenlon H, McNicholas M, McEntee G. Delayed surgical debriclement in patients with acute necrotising pancreatitis. Ir J Med Sci 2002. [DOI: 10.1007/bf03170392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Whitehouse CA, Guibeau A, McGuire D, Takeda T, Mather TN. A reverse transcriptase-polymerase chain reaction assay for detecting Highlands J virus. Avian Dis 2001; 45:605-11. [PMID: 11569733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Highlands J (HJ) virus is an arbovirus frequently recovered at high rates in mosquitoes collected in the eastern United States. HJ virus is primarily a veterinary pathogen causing disease in domestic birds including turkeys, chickens, and partridges. It has an enzootic cycle similar to eastern equine encephalitis (EEE) virus and is often used as an indicator species in EEE surveillance programs. Current immunologic techniques to identify HJ virus are often inefficient and can involve cross-reactivity of antibodies. Therefore, we developed a molecular-based assay by a reverse transcriptase (RT)-polymerase chain reaction (PCR) technique. Primers were constructed from conserved sequences of the E1 coding region from 19 strains of HJ virus. PCR amplifications from serial dilutions of HJ virus-infected Vero cell culture supernatants indicated that this assay could detect viral RNA at concentrations of 10 plaque-forming units per reaction. Extracted RNAs from western equine encephalitis, EEE, LaCrosse, and Jamestown Canyon viruses were not detected with this assay. RNA extracted directly from the brain tissue of a dead house sparrow and from a pool of Culiseta mosquitoes yielded a PCR product of the expected size. The RT-PCR technique developed was both sensitive and specific for detecting HJ virus from infected cell culture supernatants, bird brain tissues, and mosquitoes. This new assay will permit rapid and accurate diagnosis of HJ virus, both enhancing surveillance activities for EEE transmission risk and monitoring infections in domestic poultry and wild birds.
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Affiliation(s)
- C A Whitehouse
- Center for Vector-Borne Disease, University of Rhode Island, Kingston 02881, USA
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Abstract
Even in the era of highly active antiretroviral therapy, AIDS dementia remains an important and devastating complication of human immunodeficiency virus (HIV-1) infection. Based on the 1997 AIDS case rate of 56 per 100 000 population in the USA, a reasonable estimated incidence of AIDS dementia is 3-8 per 100000, similar to that of multiple sclerosis. The pharmacology of AIDS dementia has been dominated by antiretroviral therapies, the best studied of which is azidothymidine. New and specific therapies are needed to treat and prevent brain injury in the setting of HIV infection. Rational therapy has been limited by the absence of large, adequate and well-controlled clinical trials using neuroprotective agents or those with disease-modifying potential, as well as by an incomplete understanding of the pathophysiology of AIDS dementia. In this review, a summary of evidence-based hypotheses of HIV-associated brain injury is followed by information on current nonantiretroviral therapeutic trials and their scientific rationale.
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Affiliation(s)
- D McGuire
- Department of Neurology, UCSF Medical Center, San Francisco, CA, USA.
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Shoulson I, Penney J, McDermott M, Schwid S, Kayson E, Chase T, Fahn S, Greenamyre JT, Lang A, Siderowf A, Pearson N, Harrison M, Rost E, Colcher A, Lloyd M, Matthews M, Pahwa R, McGuire D, Lew MF, Schuman S, Marek K, Broshjeit S, Factor S, Brown D, Feigin A, Mazurkiewicz J, Ford B, Jennings D, Dilllon S, Comella C, Blasucci L, Janko K, Shulman L, Wiener W, Bateman-Rodriguez D, Carrion A, Suchowersky O, Lafontaine AL, Pantella C, Siemers E, Belden J, Davies R, Lannon M, Grimes D, Gray P, Martin W, Kennedy L, Adler C, Newman S, Hammerstad J, Stone C, Lewitt P, Bardram K, Mistura K, Miyasaki J, Johnston L, Cha JH, Tennis M, Panniset M, Hall J, Tetrud J, Friedlander J, Hauser R, Gauger L, Rodnitzky R, Deleo A, Dobson J, Seeberger L, Dingmann C, Tarsy D, Ryan P, Elmer L, Ruzicka D, Stacy M, Brewer M, Locke B, Baker D, Casaceli C, Day D, Florack M, Hodgeman K, Laroia N, Nobel R, Orme C, Rexo L, Rothenburgh K, Sulimowicz K, Watts A, Wratni E, Tariot P, Cox C, Leventhal C, Alderfer V, Craun AM, Frey J, McCree L, McDermott J, Cooper J, Holdich T, Read B. A randomized, controlled trial of remacemide for motor fluctuations in Parkinson's disease. Neurology 2001; 56:455-62. [PMID: 11222787 DOI: 10.1212/wnl.56.4.455] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Preclinical studies suggest that glutamate antagonists help ameliorate motor fluctuations in patients with PD treated with levodopa. METHODS In a multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-ranging study, the authors assessed the safety, tolerability, and efficacy of the glutamate receptor blocker remacemide hydrochloride in 279 patients with motor fluctuations treated with levodopa. The primary objective was to assess the short-term tolerability and safety of four dosage levels of remacemide during 7 weeks of treatment. Patients were also monitored with home diaries and the Unified PD Rating Scale (UPDRS) to collect preliminary data on treatment efficacy. RESULTS Remacemide was well tolerated up to a dosage of 300 mg/d on a twice daily schedule and 600 mg/d on a four times daily schedule. The most common dosage-related adverse events were dizziness and nausea, as observed in previous studies of remacemide. The percent "on" time and motor UPDRS scores showed trends toward improvement in the patients treated with 150 and 300 mg/d remacemide compared with placebo-treated patients, although these improvements were not significant. CONCLUSION Remacemide is a safe and tolerable adjunct to dopaminergic therapy for patients with PD and motor fluctuations. Although this study had limited power to detect therapeutic effects, the observed improvement is consistent with studies of non-human primates with 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-induced parkinsonian signs and symptoms. Additional studies are warranted to confirm these results over an extended period of observation, and to explore the potential neuroprotective effects of remacemide in slowing the progression of PD.
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Tumlin JA, Dunbar LM, Oparil S, Buckalew V, Ram CV, Mathur V, Ellis D, McGuire D, Fellmann J, Luther RR. Fenoldopam, a dopamine agonist, for hypertensive emergency: a multicenter randomized trial. Fenoldopam Study Group. Acad Emerg Med 2000; 7:653-62. [PMID: 10905644 DOI: 10.1111/j.1553-2712.2000.tb02039.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
UNLABELLED Despite successful therapies for chronic hypertension, hospital admissions for hypertensive emergency more than tripled between 1983 and 1992. OBJECTIVE To examine the safety and efficacy of fenoldopam, the first antihypertensive with selective and specific action on vascular dopamine (DA1) receptors, in a clinical trial involving emergency department patients with true hypertensive emergencies. METHODS Patients with a sustained diastolic blood pressure (DBP) of > or =120 mm Hg and evidence of target organ compromise were randomized in a double-blinded manner to one of four fixed doses of intravenous fenoldopam (0.01, 0.03, 0.1, or 0.3 microg/kg/min) for 24 hours. The primary endpoint was the magnitude of DBP reduction in each of the three higher-dose groups after four hours of fenoldopam treatment compared with the lowest-dose group. RESULTS One hundred seven participants from 21 centers were enrolled, and 94 patients received fenoldopam. Evidence of acute target-organ damage included new renal dysfunction or hematuria (50%), acute congestive heart failure or myocardial ischemia (48%), and papilledema or grade III-IV hypertensive retinopathy (34%). The DBP decreased in a dose-dependent fashion, with significant differences between the 0.1- and 0.3-microg/kg/min groups compared with the lowest-dose group. Treatment was well tolerated, and there were no deaths or serious adverse events during follow-up, up to 48 hours. All patients were successfully transitioned to oral or transdermal antihypertensives with maintenance of blood pressure control. CONCLUSIONS Fenoldopam safely and effectively lowers blood pressure in a dose-dependent manner in patients with hypertensive emergencies. Observations supporting potential risk factors for hypertensive emergency are discussed.
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Affiliation(s)
- J A Tumlin
- Emory University Hospital, Atlanta, GA, USA.
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45
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Silverberg GD, Bloch D, Kahle P, McGuire D, Saul TA, Shooter E, Sullivan EV, Levinthal EC. Effects of chronic CSF drainage on cognition and concentration of biochemical markers in Alzheimer's disease: Report of a phase I clinical trial. Neurobiol Aging 2000. [DOI: 10.1016/s0197-4580(00)83381-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Atanassoff PG, Hartmannsgruber MW, Thrasher J, Wermeling D, Longton W, Gaeta R, Singh T, Mayo M, McGuire D, Luther RR. Ziconotide, a new N-type calcium channel blocker, administered intrathecally for acute postoperative pain. Reg Anesth Pain Med 2000; 25:274-8. [PMID: 10834782 DOI: 10.1016/s1098-7339(00)90010-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVES Voltage-sensitive calcium channel conductance is essential for the nervous system to signal a painful event. However, intrathecal administration of L-type calcium channel blockers does not provide analgesia. The present investigation was designed to assess the safety and analgesic efficacy of ziconotide, a new N-type calcium channel blocker, when administered intrathecally to patients with acute postoperative pain. METHODS This randomized, double-blind, pilot study included patients undergoing elective total abdominal hysterectomy, radical prostatectomy, or total hip replacement. After intrathecal injection of local anesthetic and before surgical incision, a continuous intrathecal infusion of either placebo or 1 of 2 doses of ziconotide (0.7 microg/h or 7.0 microg/h) was started and continued for 48 to 72 hours postoperatively. Primary and secondary efficacy variables were the mean daily patient controlled analgesia (PCA) morphine equivalent consumption and visual analog pain intensity (VASPI) scores, respectively. RESULTS Thirty patients received study drug; 26 were evaluable for efficacy. Mean daily PCA morphine equivalent consumption was less in patients receiving ziconotide than in placebo-treated patients, and the difference was statistically significant between 24 and 48 hours (P = .040). VASPI scores during the first 8 hours postoperatively were markedly lower in ziconotide-treated than in placebo-treated patients. In 4 of 6 patients receiving the high-dose of ziconotide (7 microg/h), adverse events, such as dizziness, blurred vision, nystagmus, and sedation contributed to study drug being discontinued after 24 hours. After ziconotide discontinuation, these symptoms resolved. CONCLUSIONS Ziconotide showed analgesic activity, as shown by decreased PCA morphine equivalent consumption and lower VASPI scores. Because of a favorable trend of decreased morphine consumption with an acceptable side-effect profile in the low-dose ziconotide group, 0.7 microg/h may be closer to the ideal dose than 7 microg/h. Large-scale studies are required to clarify this issue.
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MESH Headings
- Acute Disease
- Adult
- Aged
- Aged, 80 and over
- Analgesia, Patient-Controlled
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Arthroplasty, Replacement, Hip
- Calcium Channel Blockers/administration & dosage
- Calcium Channel Blockers/adverse effects
- Calcium Channel Blockers/therapeutic use
- Calcium Channels, N-Type/drug effects
- Calcium Channels, N-Type/metabolism
- Double-Blind Method
- Female
- Humans
- Injections, Spinal
- Male
- Middle Aged
- Morphine/administration & dosage
- Morphine/therapeutic use
- Pain Measurement
- Pain, Postoperative/drug therapy
- Pilot Projects
- omega-Conotoxins/administration & dosage
- omega-Conotoxins/adverse effects
- omega-Conotoxins/therapeutic use
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Affiliation(s)
- P G Atanassoff
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut 06520-8051, USA.
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Mathur VS, Swan SK, Lambrecht LJ, Anjum S, Fellmann J, McGuire D, Epstein M, Luther RR. The effects of fenoldopam, a selective dopamine receptor agonist, on systemic and renal hemodynamics in normotensive subjects. Crit Care Med 1999; 27:1832-7. [PMID: 10507606 DOI: 10.1097/00003246-199909000-00021] [Citation(s) in RCA: 150] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Acute renal failure, frequently a consequence of renal vasoconstriction and subsequent renal ischemia, is a common problem for which no proven preventive or therapeutic agents exist. Fenoldopam is a new, selective, dopamine-1 receptor agonist that causes both systemic and renal arteriolar vasodilation. In hypertensive patients, fenoldopam rapidly decreases blood pressure, increases renal blood flow, and maintains or improves the glomerular filtration rate. We sought to determine a dose of fenoldopam that increases renal blood flow without inducing hypotension in normotensive patients and to explore the role of volume status (sodium replete vs. deplete) in these effects. DESIGN Randomized, double-blind, placebo-controlled, cross-over study. SETTING Clinical research unit. PATIENTS Fourteen normal male volunteers. INTERVENTIONS Renal plasma flow (para-aminohippurate clearance) and glomerular filtration rate (inulin clearance) were measured during three fixed, escalating doses of fenoldopam (0.03, 0.1, and 0.3 Lg/kg/min) on both a high-sodium and a low-sodium diet. MEASUREMENTS AND MAIN RESULTS Fenoldopam significantly increased renal plasma flow in a dose-dependent manner compared with placebo: 670 + 148 vs. 576 + 85 mUmin at 0.03 iLg/kg/min; 777 + 172 vs. 579 + 80 mUmin at 0.1 tig/kg/min; and 784 + 170 vs. 592 + 165 mUmin at 0.3 ilg/kg/min (p < .05 fenoldopam vs. placebo at all three doses). Glomerular filtration rate was maintained. At the lowest dose (i.e., 0.03 ILg/kg/min), significant renal blood flow increases occurred without changes in systemic blood pressure or heart rate. At 0.1 and 0.3 Lgl/kg/ min, systolic blood pressure did not change, but diastolic blood pressure was slightly lower in the fenoldopam group than in the placebo group: 62.5 + 6.4 vs. 63.6 + 2.6 mm Hg, respectively, at 0.3 tg/kg/min (p < .05). None of the effects of fenoldopam were altered by volume status. CONCLUSIONS Fenoldopam increased renal blood flow in a dose-dependent manner compared with placebo, and, at the lowest dose, significantly increased renal blood flow occurred without changes in systemic blood pressure or heart rate. These findings will be useful in designing future studies exploring the role of fenoldopam in preventing or treating renal failure in patients who are not hypertensive.
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Affiliation(s)
- V S Mathur
- Neurex Corporation, Menlo Park, CA 94025-1012, USA
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Ross MA, Miller RG, Berchert L, Parry G, Barohn RJ, Armon C, Bryan WW, Petajan J, Stromatt S, Goodpasture J, McGuire D. Toward earlier diagnosis of amyotrophic lateral sclerosis: revised criteria. rhCNTF ALS Study Group. Neurology 1998; 50:768-72. [PMID: 9521272 DOI: 10.1212/wnl.50.3.768] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We modified the World Federation of Neurology (WFN) diagnostic criteria for ALS to facilitate early diagnosis and used these criteria for enrollment of ALS patients in a clinical trial. The criteria developed required lower motor neuron (LMN) involvement in at least two limbs and upper motor neuron involvement in at least one region (bulbar, cervical, or lumbosacral). The EMG finding of fibrillation potentials was required for evidence of LMN involvement. Electrodiagnostic studies, neuroimaging, and laboratory studies were also used to exclude disorders that might mimic ALS. Using these criteria, the diagnosis of ALS was made at a mean time of 9.7 months from onset of symptoms, which compares favorably with the 12-month period cited in the literature. Using clinical assessment at completion of the trial, the diagnosis of ALS was believed to be accurate in those patients entered in the trial. However, pathologic confirmation of the diagnosis of ALS was not obtained. Based on our preliminary experience, we propose that these ALS diagnostic criteria will facilitate early diagnosis of ALS. Future studies should prospectively compare these criteria with the WFN criteria currently in use.
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Abstract
Pain is the most common reason for consultation with a physician, but because pain is not objectively measurable, it is often neglected or underestimated. Chronic, severe pain is a major complication of cancer and HIV-1 infection. Current therapy typically employs stepwise treatment first with nonopioid analgesics, followed by weak and then strong opioids. Nevertheless, treatment can be limited both by side effects and by the development of tolerance, and patients with neuropathic pain are often resistant to all conventional therapies. Much has been learned about the neuroanatomy and physiology of both acute and chronic pain. Drugs now being developed, such as alpha(2)-receptor agonists, the N-type calcium channel blocker, SNX-111 and NMDA antagonists, take advantage of current knowledge of the neurochemistry of pain transduction and target neurotransmitter modulation as a means of achieving analgesia. These new drugs and alternative administration methods, such as intraspinal drug delivery and preemptive analgesia for postoperative pain, should add substantially to the current analgesic armamentarium.
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Affiliation(s)
- D McGuire
- Department of Neurology, UCSF Medical Center, San Francisco, California, USA
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Miyawaki E, Lyons K, Pahwa R, Tröster AI, Hubble J, Smith D, Busenbark K, McGuire D, Michalek D, Koller WC. Motor complications of chronic levodopa therapy in Parkinson's disease. Clin Neuropharmacol 1997; 20:523-30. [PMID: 9403226 DOI: 10.1097/00002826-199712000-00004] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We report on motor complications of chronic levodopa therapy among 811 levodopa-responsive patients with idiopathic Parkinson's disease (PD), stratified by duration after diagnosis. Predictable "offs" were noted in 20.2% of patients in the first 5 years, in 58.3% after 15 years. Unpredictable or sudden offs and early morning dystonia were less common. Longer duration was associated with greater percentages of patients with off periods or dyskinesias (up to 70% after 15 years), although patients with 6-15 years' duration saw relatively little increase in frequency of those complications, and a minority of patients (approximately 30%) with duration into the second decade did not experience off periods or dyskinesia. Across groups, mean Hoehn and Yahr stage and daily levodopa dosage progressively increase (and mean Schwab and England disability ratings decrease), but more conservatively than in prior reports in the postlevodopa era. We note that with advancing PD duration, levodopa complications are more common, but in many cases there appear to be relatively stable periods in terms of levodopa dosage and disease severity, and a minority of patients will be relatively free of motor complications into the second decade of their disease.
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Affiliation(s)
- E Miyawaki
- Department of Neurology, University of Kansas Medical Center, Kansas City 66160-7314, USA
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