Safety and acceptability of clozapine and risperidone in progressive multiple sclerosis: a phase I, randomised, blinded, placebo-controlled trial

Objective

Because clozapine and risperidone have been shown to reduce neuroinflammation in humans and mice, the Clozapine and Risperidone in Progressive Multiple Sclerosis (CRISP) trial was conducted to determine whether clozapine and risperidone are suitable for progressive multiple sclerosis (pMS).

Methods

The CRISP trial (ACTRN12616000178448) was a blinded, randomised, placebo-controlled trial with three parallel arms (n=12/arm). Participants with pMS were randomised to clozapine (100–150 mg/day), risperidone (2.0–3.5 mg/day) or placebo for 6 months. The primary outcome measures were safety (adverse events (AEs)/serious adverse events (SAE)) and acceptability (Treatment Satisfaction Questionnaire for Medication-9).

Results

An interim analysis (n=9) revealed significant differences in the time-on-trial between treatment groups and placebo (p=0.030 and 0.025, clozapine and risperidone, respectively) with all participants receiving clozapine being withdrawn during the titration period (mean dose=35±15 mg/day). Participants receiving clozapine or risperidone reported a significantly higher rate of AEs than placebo (p=0.00001) but not SAEs. Specifically, low doses of clozapine appeared to cause an acute and dose-related intoxicant effect in patients with pMS who had fairly severe chronic spastic ataxic gait and worsening over all mobility, which resolved on drug cessation.

Interpretation

The CRISP trial results suggest that patients with pMS may experience increased sensitivity to clozapine and risperidone and indicate that the dose and/or titration schedule developed for schizophrenia may not be suitable for pMS. While these findings do not negate the potential of these drugs to reduce multiple sclerosis-associated neuroinflammation, they highlight the need for further research to understand the pharmacodynamic profile and effect of clozapine and risperidone in patients with pMS.

Trial registration number

ACTRN12616000178448.

Effects of high ambient temperature on respiration rate, rectal temperature, fetal development and thyrold gland activity in tropical and temperate breeds of sheep

The effects of high ambient temperatures on rectal temperature (RT), respiration rate (RR), fetal development and serum thyroxine (T(4)) concentrations were stuaied in two experiments involving 35 ewes and 26 lambs from the following ewe groups: 1) Barbados Blackbelly (B), a tropical breed; 2) Dorset (D), a temperate breed; and 3) Blackbelly x Dorset crosses (BxD). Data were obtained on four B, five D and five BxD ewes exhibiting estrus during the summer (Exp. 1). In Exp. 2, eight B, seven D and six BxD ewes were maintained in two environmental chambers (cool, 22.2C; hot, 33.8C) from day 125 of gestation to seven days before the expected lambing date for each breed group (D and BxD, 140+/-1; B, 144+/-1 day of gestation). The B and BxD ewes were more heat-tolerant than D ewes as measured by significantly lower RT and RR in each experiment. Mean lamb birth weight, crown-rump length, number of functional uterine caruncles and caruncle weight and size did not vary significantly among breed groups or temperature chamber (Exp. 2), and there was no indication that the high temperature imposed caused fetal dwarfing in lambs removed from the uterus at a standard age of seven days before expected parturition. Serum T(4) varied markedly among breed groups (P<0.05) in each experiment with B ewes having the lowest and BxD ewes the highest concentration. In Exp. 1, follicular stage T(4) concentrations in B and BxD ewes were lower (P<0.02) than those during the luteal stage of the estrous cycle. The decrease in D ewes was not significant. High ambient temperature (Exp. 2) depressed T(4) levels in D ewes (P<0.05) and also depressed the pituitary-thyroid response to thyrotropin releasing hormone in D lambs. Such was not the case in B and BxD ewes and their lambs.

Sustaining the development of primary care in academic medicine. Working Group on Sustaining the Development of Academic Primary Care. Association of American Medical Colleges

This article is the report of the Working Group on Sustaining the Development of Academic Primary Care, one of the six subgroups of the Advisory Panel on the Mission and Organization of Medical Schools (APMOMS) sponsored by the Association of American Medical Colleges (AAMC). To begin, the group draws a distinction between primary care and generalism. Primary care is a core domain of health care and, in the context of emerging integrated systems, will increasingly be a multidisciplinary shared function. Non-subspecialized physicians, or "generalists," are a key element in the provision of primary care, but do not act alone. Core competencies for primary care are central to the education of all physicians. Therefore, irrespective of workforce goals for generalist physicians, primary care should have a strong, central position in the medical school so that graduates can receive a sound general medical education and can be prepared for any specialty and for lifelong learning in an evolving health care system. For primary care to achieve that position, medical schools must integrate primary care into their missions, strategic plans, operation, organization, academic administrative structures, curriculum development, faculty development (both school- and community-based), resource development, alliances with appropriate clinical services networks, financial policy, and evaluation and educational monitoring systems. The group briefly describes the elements of those changes and also proposes ways that the AAMC and medical school leaders could promote the central role of primary care in medical schools.

Detection of human growth hormone receptors on IM-9 cells and peripheral blood mononuclear cell subsets by flow cytometry: correlation with growth hormone-binding protein levels

We have developed a method using flow cytometry to identify fluorescein-conjugated GH receptors (GHR) on IM-9 lymphocytes and circulating peripheral blood mononuclear cell subsets. Binding to IM-9 cells and peripheral blood mononuclear cells was concentration dependent and could be competitively blocked by the addition of unlabeled human GH, but not by the addition of rat or bovine GH or human insulin or PRL. Using two-color flow cytometric analysis, fluorescein-conjugated human GHR were readily detected on more than 90% of B lymphocytes and monocytes, but only variably on T lymphocytes. B Lymphocytes and monocytes had approximately 6000 GHR/cell. Using two-color flow cytometry, we identified GHR on circulating B lymphocytes in subjects with GH deficiency (n = 9), precocious puberty (n = 6), and Turner syndrome (n = 5) and in seven subjects with miscellaneous disorders, including familial short stature, bone dysplasia, Crohn disease, congenital adrenal hyperplasia, and acromegaly. The percentage of B lymphocytes expressing GHR in subjects with GH deficiency (mean +/- SD, 95 +/- 9%), precocious puberty (91 +/- 15%), and Turner syndrome (84 +/- 15%) was not different from that in normal volunteers (90 +/- 12%; n = 14). In 10 subjects, serum GH-binding protein levels were assayed simultaneously with B lymphocyte GHR. GH-binding protein was normal in all (mean, 1255 pmol/L; range, 773-1809). There was a good correlation between GHR expression on B lymphocytes and GH-binding protein levels (r = 0.75; P = 0.01). We postulate that GHR found on circulating B lymphocytes may contribute to the pool of receptors identified in serum as GH-binding proteins. Two-color flow cytometry appears to be an effective method for the detection of GHR on circulating peripheral blood mononuclear cell subsets. The evaluation of GHR on circulating B lymphocytes may prove to be a useful means of evaluating GH-GHR interactions in subjects with growth disorders.

Effects of rapid weight gain to puberty on reproduction, mammary development and lactation in ewe lambs

The effects of rapid weight gain to puberty on reproduction, mammary development and milk production in ewes lambing at 13 mo of age were investigated on three trials. A total of 64 Dorset and 93 Suffolk ewe lambs were weaned at 42 d of age and their mean weight was 16 kg. These ewes were assigned, within breed groups, to either a finishing diet or a growing diet. Onset of puberty was determined by daily checks for estrus and ewes were bred beginning at 7 mo of age. In Trial 2, mammary gland development was determined in eight Suffolk ewes from each diet. Ewes on the finishing diet were younger at puberty than those on the growing diet (199 vs 206 d, P<0.05) but required more services per conception (1.3 vs 1.1, P<0.05). Dietary conception rate and lambing rate means were similar. Mean 4-h milk yield was lower (P<0.10) for ewes on the finishing diet (283 g) than for those on the growing diet (310 g). Mammary gland fat pad area was higher (P<0.05) for ewes on the finishing diet compared with those fed for growth. Gross and adjusted duct areas were higher in ewes on the growing diet, but differences were not significant. At puberty, negative correlation coefficients for milk yield with performance traits were as follows: daily weight gain, -0.184 (P<0.08); weight-to-height ratio -0.262 (P<0.01); body condition score, -0.189 (P<0.07); and body weight, -0.212 (P<0.05). Results of this study indicate that rapid weight gain to puberty impairs mammary gland development and milk production in ewe lambs.

Effects of dietary iron on performance and mineral utilization in lambs fed a forage-based diet

Twenty-four lambs, averaging 29 kg, were used to determine the effect of supplemental dietary Fe on performance and Cu, P, Zn and Mn utilization. Treatments consisted of supplemental Fe at 0, 300, 600 or 1,200 mg/kg diet as ferrous carbonate. The basal diet contained 154 mg Fe/kg diet and consisted of 90% Coastal bermudagrass pellets, 9.45% group corn, .5% sodium chloride and .05% vitamin mix. Lambs were slaughtered after having ad libitum access to diets for 98 to 121 d. Dietary Fe did not affect lamb gain or feed intake. Supplemental Fe increased Fe concentrations in liver (P less than .01), spleen (P less than .01) and bone (P less than .10), but not in kidney and muscle. Serum Fe concentrations and percentage transferrin saturation in serum were increased (P less than .01) by supplemental Fe at 28 and 84 d, but not at the termination of the study. Plasma Cu was decreased (P less than .01) at 56 d, whereas serum ceruloplasmin activity was reduced (P less than .01) at 28 d in lambs fed 1,200 mg Fe/kg diet compared with lambs fed 600 mg Fe/kg diet. Lower levels of Fe (300 and 600) reduced (P less than .01) ceruloplasmin by 56 d and plasma Cu by 84 d compared with controls. Liver Cu also was decreased (P less than .05) by supplemental Fe. Plasma P was decreased slightly (P less than .10) by 28 d and significantly (P less than .01) at the other sampling dates by supplemental Fe.(ABSTRACT TRUNCATED AT 250 WORDS)

Voluntary intake, gain, digestibility, rate of passage and gastrointestinal tract fill in tropical and temperate breeds of sheep

In trial 1, Coastal bermudagrass pellets were fed for 63 d to 21 growing rams of Barbados Blackbelly (B), Dorset (D) and Blackbelly X Dorset (B X D) breeding to determine the effect of breed on voluntary intake (VI) and total gain. Initially, each breed group consisted of seven rams with mean weights of 18.6, 31.0 and 26.4 kg, respectively. At the end of the intake and growth phase, digestibility, rate of passage and gastrointestinal tract (GIT) fill were determined. Chromium-mordanted fiber was used as a particle phase marker. Intakes during the digestibility-marker phase averaged 75% of the VI determined in the intake and growth phase. Breeds did not differ in VI, total gain or digestibilities of dry matter (DM) and neutral detergent fiber (NDF). Apparent crude protein (CP) digestibility was approximately 3 percentage units higher (P less than .10) for B X D than for B or D rams. Rate of passage was faster (P less than .05) for B X D rams than for the other breed groups, while D rams were intermediate. Total mean retention time (MRT) was shorter (P less than .05) for B X D rams compared with the other breed groups. Ruminal retention time (RRT) was shorter (P less than .05) and GIT fill was less (P less than .10) for D and B X D than for B rams. In trial 2, chopped orchardgrass-alfalfa hay was fed for 26 d to 19 of the same rams used in trial 1. Breed, number of rams and initial weights (kg) were: B, 5, 25.6; D, 7, 39.4; B X D, 7, 35.0.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of accelerated growth during rearing on reproduction and lactation in ewes lambing at 13 to 15 months of age

Three trials were conducted using ewe lambs to determine the effects of accelerated growth during rearing on reproduction and lactation. Data were obtained on 113 ewes. Early weaned ewe lambs were randomly assigned to the following prebreeding treatments: (1) thin (T, moderate gain) and (2) fat (F, accelerated gain). They were bred to lamb at 13 to 15 months of age. After breeding, one half of the ewes on the T and F treatments were switched to the other treatment so that postbreeding treatments were TT, TF, FF and FT. Prebreeding treatment did not affect conception rate (T, 95%; F, 96%), but lambing rates were 43, 28 and 27% higher (P<0.05) for F than T ewes in trials 1, 2 and 3, respectively. Daily milk production was higher in T ewes than F ewes for each trial, but the differences were significant only in trial 3. Estimated daily milk yields over the 60-day period were: T ewes, 1482, 1571, 1614 g; F ewes, 1183, 1373, 1321 g for trials 1, 2 and 3, respectively. Number of alveoli also favored T ewes. Switching ewes to the alternate treatment after breeding did not affect reproduction or milk production. Correlations between weight to height ratio and milk yield were negative in trials 1 and 3 but were positive in trial 2. There was no indication that serum T(4) levels affected milk production or reproduction. The results of this study show that accelerated growth during rearing increased lambing rate but may impair milk production. These effects appeared to be fixed by the time the ewes were bred.

Relationship between rat heat stress mortality and alterations in reticuloendothelial carbon clearance function

It has recently been reported that, although bacterial endotoxins of intestinal origin are not associated with death after experimental rat heat stress, a state of endotoxin tolerance significantly decreases the heat stress mortality rate. To determine if this phenomenon were associated with the ability of endotoxins to stimulate clearance by the reticuloendothelial system (RES), the relationship between rat heat stress mortality and carbon clearance by the RES was examined. RES carbon clearance was stimulated by prior treatment with endotoxin, zymosan, or sublethal heat stress, as indicated by the significantly reduced (p less than 0.05) blood carbon concentrations 15 min after carbon injections. Prior treatment with injections of gelatin blocked RES carbon clearance. Rats subjected to endotoxin or sublethal heat treatment were significantly (p less than 0.05) resistant to the experimental heat stress, whereas zymosan treatment had no effect. Blockade of the RES with gelatin significantly (p less than 0.05) increased the heat stress mortality rate. These data compare favorably with previously reported studies evaluating RES function and mortality after experimental injury and shock and indicate that the RES may play a fundamental role in the pathogenesis of, and tolerance to, experimental heat stress.

Haemonchus contortus resistance in straightbred and crossbred Barbados Blackbelly sheep

Resistance to Haemonchus contortus infection was studied in two experiments conducted with 52 lambs of widely different genetic background. Breed groups compared were: Dorset (D), Barbados Blackbelly (B), Dorset x Blackbelly (D x B), Suffolk x Blackbelly (S x B), Suffolk x Dorset x Blackbelly (S x D x B,[1/4 B]) and nonBlackbelly (NB, D and S). In each experiment, lambs were raised on concrete from birth and were essentially parasite free until infective larvae were administered. In Exp. 1, D x B, S x D x B and D wether lambs approximately 3 months old were infected with a standard dose of invective larvae estimated to be 98% H. contortus. D x B lambs had a longer (P < .05) prepatency period and, at necropsy 17-day postinfection, had a higher (P < .05) percentage of female parasites classified as immature than did the other breed groups. These data showed that the development of H. contortus larvae was inhibited in D x B host animals. In Exp. 2, B, D x B, S x B and NB ewe and wether lambs approximately 4 months old were treated with three sensitizing doses of H. contortus larvae. These were followed by a challenge infection. On the basis of fecal egg counts (eggs per gram feces, EPG), there was no evidence that the challenge infection induced a self-cure reaction in any breed group. All lambs with B breeding had significantly higher Hb levels at the end of the experiment than did NB lambs. b and S x B lambs had higher (P < .05) Hb levels than the D x B lambs, and B lambs had the highest (P < .05) mean corpuscular hemoglobin concentrations. Five days after the challenge infection, B, D x B and S x B lambs also had significantly higher white blood cell levels than did NB lambs. Significant sex differences were also observed in Exp. 2. Ewe lambs had lower final EPG levels, higher preinfection and postinfection Hb levels and higher maximum postinfection cosinophil levels. Breed x sex interactions for these parameters were not significant.

Neuraminidase activity in bacterial meningitis

The relation of neuraminidase to morbidity and mortality was examined in patients with Haemophilus influenzae, meningococcal, and pneumococcal meningitis. Ten strains of H. influenzae and eight strains of meningococci from infected cerebrospinal fluid (CSF) did not elaborate neuraminidase. Each of 27 strains of pneumococci from infected CSF elaborated both neuraminidase and N-acetylneuraminic acid (NANA) aldolase. There was no correlation between amount of neuraminidase secreted in vitro and survival of patients. Values for free and total NANA concentrations were derived from admission CSF samples of 63 patients with meningitis; 18 patients infected with Neisseria meningitidis, 10 with H. influenzae and 35 with Diplococcus pneumoniae. Mean values for total NANA were elevated in each type of bacterial meningitis; however, abnormal concentrations of free CSF NANA were detected only in 17 patients with pneumococcal meningitis. 11 of 18 patients with pneumococcal meningitis showing normal free CSF NANA concentrations were cured, whereas only 4 patients with abnormal free NANA levels survived without residua. Both coma and bacteremia occurred significantly more often among patients with elevated concentrations of free CSF NANA. The association of elevated concentrations of free CSF NANA with coma and with an adverse prognosis suggested that neuraminidase may be a factor in the pathogenesis of penumococcal meningitis.