Cognitive behavioral therapy for managing depressive and anxiety symptoms after brain injury: a meta-analysis

BACKGROUND

Individuals with traumatic brain injury (TBI) are at increased risk of depression and anxiety, leading to impaired recovery. While cognitive-behavioral therapy (CBT) addresses anxiety and depression maintenance factors, its efficacy among those with TBI has not been clearly demonstrated. This review aims to bridge this gap in the literature.

METHODS

Several databases, including Medline, PsycInfo and EMBASE, were used to identify studies published between 1990 and 2021. Studies were included if: (1) trials were randomized controlled trials (RCT) involving CBT-based intervention targeting anxiety and/or depression; (2) participants experienced brain injury at least 3-months previous; (3) participants were ≥18 years old. An SMD ± SE, 95% CI and heterogeneity were calculated for each outcome.

RESULTS

Thirteen RCTs were included in this meta-analysis. The pooled-sample analyses suggest that CBT interventions had small immediate post-treatment effects on reducing depression (SMD ± SE: 0.391 ± 0.126, p < 0.005) and anxiety (SMD ± SE: 0.247 ± 0.081, p < 0.005). Effects were sustained at a 3-months follow-up for depression. A larger effect for CBT was seen when compared with supportive therapy than control. Another sub-analysis found that individualized CBT resulted in a slightly higher effect compared to group-based CBT.

CONCLUSION

This meta-analysis provides substantial evidence for CBT in managing anxiety and depression post-TBI.

Reducing endocrine metabolic disease risk in adults with chronic spinal cord injury: strategic activities conducted by the Ontario-Quebec RIISC team

PURPOSE

The Rehabilitation Interventions for Individuals with a Spinal Cord Injury in the Community (RIISC) team aimed to develop and evaluate innovative rehabilitation interventions to identify endocrine metabolic disease (EMD) risk, intending to reduce the frequency and severity of EMD related morbidity and mortality among adults living with chronic spinal cord injury or disease (SCI/D).

MATERIALS AND METHODS

An interprovincial team from Ontario and Quebec reviewed available EMD literature and evidence syntheses and completed an inventory of health services, policies and practices in SCI/D care. The review outcomes were combined with expert opinion to create an EMD risk model to inform health service transformation.

RESULTS

EMD risk and mortality are highly prevalent among adults with chronic SCI/D. In stark contrast, few rehabilitation interventions target EMD outcomes. The modelled solution proposes: 1) abandoning single-disease paradigms and examining a holistic perspective of the individual's EMD risk, and 2) developing and disseminating practice-based research approaches in outpatient community settings.

CONCLUSIONS

RIISC model adoption could accelerate EMD care optimization, and ultimately inform the design of large-scale longitudinal pragmatic trials likely to improve health outcomes. Linking the RIISC team activities to economic evaluations and policy deliverables will strengthen the relevance and impact among policymakers, health care providers and patients.

Internet-based sexual health resources for those living with spinal cord injury: A content analysis

CONTEXT

Spinal cord injuries (SCIs) disrupt physiological functioning which can significantly impact sexuality. Those with SCI may rely heavily on Internet sexual health resources for many reasons. Evaluation of current internet health resources is warranted to identify the gaps in the literature.

OBJECTIVES

The aim of this study was to conduct a purposive review of available Internet sexual health resources for those with SCI.

METHODS

A Google search was completed with search terms such as: "SCI and sexual functioning", "SCI and sexuality", "SCI and pregnancy" and "SCI and sexual pleasure". Resources were selected if they: (1) provided sexual health education to those with SCI; (2) were designed to increase skills-based learning or influence attitudes and beliefs; and (3) in English language. All identified resources were imported to NVivo 1.5.1 where a thematic content analysis was conducted.

RESULTS

The search resulted in 123 resources meeting the criteria. The most common themes included: Sexual functioning (in 83.7% of resources), Reproductive health (67.5%) and Impact of Secondary Complications (61.8%). The least common themes were Psychosocial (24.4%), Stigma (13.8%), and Quality of Life (12.2%). No information was coded for LGBTQ+.

DISCUSSION

Sexual health and SCI information focuses primarily on heterosexual males and specifically on sexual functioning. Resources addressing female sexuality were extremely limited and focused largely on reproduction. There was a complete absence of resource aimed to address LGBTQ+ people.

CONCLUSION

The results demonstrate a need for Internet-based sexual health education resources to meet the needs of diverse individuals including women and gender non-conforming people.

Conception and development of Self-Management indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

CONTEXT

Although self-management is linked to reduced secondary health complications (SHCs) and enhanced overall quality of life post-spinal cord injury or disease (SCI/D), it is poorly integrated into the current rehabilitation process. Promoting self-management and assuring equity in care delivery is critical. Herein, we describe the selection of Self-Management structure, process and outcome indicators for adults with SCI/D in the first 18 months after rehabilitation admission.

METHODS

Experts in self-management across Canada completed the following tasks: (1) defined the Self-Management construct; (2) conducted a systematic search of available outcomes and their psychometric properties; and (3) created a Driver diagram summarizing available evidence related to Self-Management. Facilitated meetings allowed development and selection following rapid-cycle evaluations of proposed structure, process and outcome indicators.

RESULTS

The structure indicator is the proportion of staff with appropriate education and training in self-management principles. The process indicator is the proportion of SCI/D inpatients who have received a self-management assessment related to specific patient self-management goal(s) within 30 days of admission. The outcome indicator is the Skill and Technique Acquisition, and Self-Monitoring and Insight subscores of the modified Health Education Impact Questionnaire.

CONCLUSION

The structure indicator will heighten awareness among administrators and policy makers regarding the need to provide staff with ongoing training related to promoting self-management skill acquisition. Successful implementation of the Self-Management process and outcome indicators will promote self-management education and skill acquisition as a rehabilitation priority, allow for personalization of skills related to the individual's self-management goal(s), and empower individuals with SCI/D to manage their health and daily activities while successfully integrating into the community.

Knowledge Synthesis in Evidence-Based Medicine

Systematic reviews are the most common form of knowledge synthesis and remain a cornerstone of the practice of evidence-based medicine. They offer enhanced rigor and validity relative to traditional narrative review articles by reducing bias and increasing objectivity. In answering focused research questions, systematic reviews are directly applicable to clinical practice as well as the development of clinical guidelines and the identification of knowledge gaps, which may drive future primary research directions. Typically, such a rigorous process necessarily requires substantive time to carefully and systematically identify, screen, and synthesize all relevant available primary research on a topic. Further, other knowledge synthesis methods have emerged to address the varying needs of decision makers with respect to condensed timelines and more diverse research questions, as well as to allow incorporation of already synthesized evidence into reviews. These alternative methods include rapid reviews, scoping reviews, and overviews of systematic reviews, which are being used with increasing frequency by clinicians, decision-makers, and researchers. We encourage clinicians and researchers in nuclear medicine and other imaging sciences to acquire a greater familiarity with these methods and to consider them in clinical decision making, the development of clinical guidelines, and the planning of future research activities.

Facilitators and Barriers for Implementing an Internet Clinic for the Treatment of Pressure Injuries

Background: Pressure injuries (PIs) represent a frequent, often preventable, secondary complication of spinal cord injury (SCI) with serious consequences to health, societal participation, and quality of life. Specialized knowledge and service delivery related to treatment and prevention are typically located within major health centers. Introduction: For persons with SCI living at home, it can be challenging to access specialized PI care. A telehealth approach could help mitigate this challenge. This multisite pilot investigation assessed the feasibility of integrating information technologies within the management of PIs. Materials and Methods: Each study site formed a specialized interdisciplinary care team that identified components of their standard clinical care pathway and examined how they could be integrated with study technologies. A monitoring system was utilized to enable patients and caregivers to exchange clinical information with the care team. Results: Clinician and patient focus groups were completed to identify facilitators and barriers for long-term implementation. Findings demonstrate that this method of service delivery is feasible but requires further development. Discussion: This model of care requires refinement to address technological, regulatory, and clinician acceptance barriers; however, increased access to these services has the potential for improving PI healing or prevention rates in comparison with those not able to access specialized services. Conclusions: This project demonstrates that PI treatment services can be delivered effectively through the internet. Future trials can investigate efficacy and cost-effectiveness of this model of care to inform sustained implementation.

Refractory Pseudomonas Bacteremia in a 2-Year-Old Sterilized by Bacteriophage Therapy

Here, we report a complex case that involved a pediatric patient who experienced recalcitrant multidrug-resistant Pseudomonas aeruginosa infection complicated by bacteremia/sepsis; our antibacterial options were limited because of resistance, allergies, and suboptimal source control. A cocktail of 2 bacteriophages targeting the infectious organism introduced on 2 separate occasions sterilized the bacteremia.

Self-management interventions for skin care in people with a spinal cord injury: part 1-a systematic review of intervention content and effectiveness

Study design

Systematic review.

Objectives

To review the content and effectiveness of skin care self-management interventions for people with SCI.

Setting

International.

Methods

We searched electronic bibliographic databases, trial registers, and relevant reference lists. Eligibility criteria for the reviews of intervention content and effectiveness were identical with the exception of study design. The review of intervention content included non-randomized and randomized controlled trials (RCTs). The review of effectiveness included RCTs. A Behavior Change Technique (BCT) taxonomy of 93 BCTs was used to code intervention content. Intervention effects on outcomes of interest are summarized descriptively. Effect sizes were calculated, and the Cochrane risk of bias tool applied.

Results

In all, 15 studies testing 17 interventions were included in the review of intervention content. Interventions in these studies included 28 BCTs. The most common were “instructions on how to perform behavior” (16 interventions), “credible source” (12 interventions), and “social support (unspecified)” (9 interventions). Ten RCTs were included in the review of intervention effectiveness and they measured knowledge, self-efficacy, and skills relating to skin care/pressure ulcer (PU) prevention, skin care behaviors, skin status (PU prevalence, severity, and time to PU), and health-care utilization for skin problems. Evidence to support intervention effects on these outcomes was limited, particularly for clinical outcomes. Risk of bias assessments was often inconclusive due to poor reporting.

Conclusions

There is potential to design SCI skin care interventions that include currently untested BCTs. Further research and better consistency in outcome measurements and reporting are required to synthesize evidence on effectiveness.

Using a Modified ADAPTE Process to Enable Effective Implementation of Electrical Stimulation Therapy for Treating Pressure Ulcers in Persons With Spinal Cord Injury

Objectives:

To apply a modified ADAPTE process to adapt best practices to a local context for successful implementation of electrical stimulation therapy (EST) for treating pressure injuries in persons with spinal cord injury (SCI).

Participants:

An expert team of health care professionals and a consumer participated in a 2-day workshop to assist in the development of the locally adapted EST document in Southwest Ontario, Canada.

Results:

A process map illustrating the flow of activities to initiate EST for treating pressure injuries in persons with SCI based on the challenges and opportunities existing within this region was created. The team also developed a summary of roles and responsibilities delineating tasks specific to providing EST and identified a set of challenges likely to be encountered.

Conclusions:

The modified ADAPTE process provided a clear and flexible structure to adaptation when used for implementation planning. This article shares some challenges associated with using this process for local adaptation and shares strategies of improvement for future studies aimed at adapting a practice to their local environment.

[Not Available]

A cross was made of Elymus repens onto the wheat cultivar Crocus and BC1 progeny advanced to BC1F7 by single seed descent. Sixteen lines were selected based on agronomic performance and evaluated in an FHB epiphytotic nursery. Eight lines with FHB resistance were selected. Based on GISH analysis, line P1142-3-1-5 had 42 chromosomes with one pair of chromosomes showing telomeric translocations on both arms. This chromosome was identified as 3D by using SSR markers. An evaluation of lines with single translocations revealed that FHB resistance was contributed by the translocation on the long arm of chromosome 3D. That line has minimal linkage drag and should be amenable to applications in breeding for disease resistance.

The CanPain SCI Clinical Practice Guidelines for Rehabilitation Management of Neuropathic Pain after Spinal Cord: introduction, methodology and recommendation overview

STUDY DESIGN

Clinical practice guidelines.

OBJECTIVES

The objective was to develop the first Canadian clinical practice guidelines for the management of neuropathic pain in people with spinal cord injury (SCI).

SETTING

The guidelines are relevant for inpatient and outpatient SCI rehabilitation settings in Canada.

METHODS

The guidelines were developed in accordance with the Appraisal of Guidelines for Research and Evaluation II tool. A Steering Committee and Working Group reviewed the relevant evidence on neuropathic pain management (encompassing screening and diagnosis, treatment and models of care) after SCI. The quality of evidence was scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE). A consensus process was followed to achieve agreement on recommendations and clinical considerations.

RESULTS

The Working Group developed 12 recommendations for screening and diagnosis, 12 recommendations for treatment and 5 recommendations for models of care. Important clinical considerations accompany each recommendation.

CONCLUSIONS

The Working Group recommendations for the management of neuropathic pain after SCI should be used to inform practice.

Effects of a Functional Electrical Stimulation-Assisted Cycling Program on Immune and Cardiovascular Health in Persons with Spinal Cord Injury

Background: Spinal cord injury (SCI) is associated with both a state of chronic inflammation and an increased prevalence of cardiovascular disease (CVD). These disorders are closely linked and have been shown to negatively influence one another. Participation in regular exercise has been shown to be an effective intervention strategy in the treatment of each of these disorders. For individuals with SCI who may lack the lower limb motor capabilities to perform certain traditional exercise modalities, functional electrical stimulation (FES) cycling may provide an effective alternative. Objective: The purpose of this study was to examine the effects of 12 weeks of FES training performed 3 times per week on physiological indices of cardiovascular function as well as molecular indices of inflammation and cardiovascular health. Methods: Ten individuals with chronic SCI were included. Measures of central and peripheral cardiovascular function as well as hematological and immunological markers were assessed before and after the 12-week exercise program. Results: Enhancements in exercise performance as well as a corresponding increase in peripheral cardiovascular function were achieved, as shown by a significant 34% increase in pulse volume (P = .04) and trends toward increases in cross-sectional area (P = .09) and arterial inflow volume (P = .11) of the common femoral artery. Despite this, no change in any hematological or immunological markers was evident. Conclusion: Although the efficacy of FES exercise in enhancing exercise performance (time and distance to fatigue) and peripheral cardiovascular function has been reaffirmed, no alterations in any molecular indices of cardiovascular risk were achieved.

Geomorphic and geologic controls of geohazards induced by Nepal's 2015 Gorkha earthquake

The Gorkha earthquake (magnitude 7.8) on 25 April 2015 and later aftershocks struck South Asia, killing ~9000 people and damaging a large region. Supported by a large campaign of responsive satellite data acquisitions over the earthquake disaster zone, our team undertook a satellite image survey of the earthquakes' induced geohazards in Nepal and China and an assessment of the geomorphic, tectonic, and lithologic controls on quake-induced landslides. Timely analysis and communication aided response and recovery and informed decision-makers. We mapped 4312 coseismic and postseismic landslides. We also surveyed 491 glacier lakes for earthquake damage but found only nine landslide-impacted lakes and no visible satellite evidence of outbursts. Landslide densities correlate with slope, peak ground acceleration, surface downdrop, and specific metamorphic lithologies and large plutonic intrusions.

Human rights and access to hepatitis C treatment for people who inject drugs

BACKGROUND

People who inject drugs (PWID) achieve adherence to and outcomes from hepatitis C virus (HCV) treatment comparable to other patients. Nonetheless, this population has been excluded from treatment by regulation or practice. Approval of safer and more effective oral HCV medicines should offer greater treatment options for PWID, although high medicine prices have led to continued treatment rationing and exclusion in developed countries. In middle-income countries (MICS), treatment is largely unavailable and unaffordable for most PWID.

METHODS

Human rights analysis, with its emphasis on the universal and interconnected nature of the economic, social and political spheres, offers a useful framework for HCV treatment reform. Using peer-reviewed and grey literature, as well as community case reports, we discuss barriers to treatment, correlate these barriers to rights violations, and highlight examples of community advocacy to increase treatment for PWID.

RESULTS

Structural drivers of lack of treatment access for PWID include stigma in health settings; drug use status as a criterion for treatment exclusion; requirements for fees or registration by name as a drug user prior to treatment initiation; and incarceration/detention in prisons and rehabilitation centers where treatment is unavailable. High medicine prices force further exclusion of PWID, with cost containment masked as concern about treatment adherence. These barriers correlate to multiple rights violations, including of the rights to privacy; non-discrimination; health; freedom of information; fair trial; and freedom from cruel, inhuman and degrading treatment.

CONCLUSIONS

Needed reforms include decriminalization of drug use, possession of drugs and drug injecting equipment; removal of exclusionary or discriminatory treatment protocols; approaches to strengthen links between health providers and increase participation of PWID in treatment design and implementation; and measures to increase transparency in government/pharmaceutical company negotiations and reduce treatment price.

Examining the effectiveness of intrathecal baclofen on spasticity in individuals with chronic spinal cord injury: a systematic review

OBJECTIVE

To review the available evidence on the effectiveness of intrathecal baclofen in the treatment of spasticity in individuals with spinal cord injuries (SCIs) at least 6 months post-injury or diagnosis.

DATA SOURCES

A literature search of multiple databases (Pub Med, CINAHL, EMBASE) was conducted to identify articles published in the English language.

STUDY SELECTION

Studies were included for review if: (1) more than 50% of the sample size had suffered a traumatic or non-traumatic SCI; (2) there were more than three subjects; (3) subjects received continuous intrathecal baclofen via an implantable pump aimed at improving spasticity; and (4) all subjects were ≥6 months post-SCI, at the time of the intervention.

DATA EXTRACTION

Data extracted from the studies included patient and treatment characteristics, study design, method of assessment, and outcomes of the intervention.

DATA SYNTHESIS

Methodological quality was assessed using the PEDro for randomized-controlled trials (RCTs) and the Downs and Black (D&B) tool for non-RCTs. A level of evidence was assigned to each intervention using a modified Sackett scale.

CONCLUSION

The literature search resulted in 677 articles. No RCTs and eight non-RCTs (D&B scores 13-24) met criteria for inclusion, providing a pooled sample size of 162 individuals. There was substantial level 4 evidence that intrathecal baclofen is effective in reducing spasticity. Mean Ashworth scores reduced from 3.1-4.5 at baseline to 1.0-2.0 (P < 0.005) at follow-up (range 2-41 months). Average dosing increased from 57-187 µg/day at baseline to 218.7-535.9 µg/day at follow-up. Several complications from the use of intrathecal baclofen or pump and catheter malfunction were reported.

Comparative effectiveness of antinociceptive gene therapies in animal models of diabetic neuropathic pain

Peripheral neuropathic pain is one of the most common and debilitating complications of diabetes. Several genes have been shown to be effective in reducing neuropathic pain in animal models of diabetes after transfer to the dorsal root ganglion using replication-defective herpes simplex virus (HSV)1-based vectors, yet there has never been a comparative analysis of their efficacy. We compared four different HSV1-based vectors engineered to produce one of two opioid receptor agonists (enkephalin or endomorphin), or one of two isoforms of glutamic acid decarboxylase (GAD65 or GAD67), alone and in combination, in the streptozotocin-induced diabetic rat and mouse models. Our results indicate that a single subcutaneous hindpaw inoculation of vectors expressing GAD65 or GAD67 reduced diabetes-induced mechanical allodynia to a degree that was greater than daily injections of gabapentin in rats. Diabetic mice that developed thermal hyperalgesia also responded to GAD65 or endomorphin gene delivery. The results suggest that either GAD65 or GAD67 vectors are the most effective in the treatment of diabetic pain. The vector combinations, GAD67+endomorphin, GAD67+enkephalin or endomorphin+enkephalin also produced a significant antinociceptive effect but the combination did not appear to be superior to single gene treatment. These findings provide further justification for the clinical development of antinociceptive gene therapies for the treatment of diabetic peripheral neuropathies.

Secretion of PGF2alpha and oxytocin during hyperthermia in cyclic and pregnant heifers

The effects of acute heat stress (HS) and oxytocin (OT) injection on plasma concentrations of PGF2alpha and OT were examined in cyclic (C; n = 15) and pregnant (P; n = 11) dairy heifers. On Day 17 of synchronized estrous cycles, animals were randomly assigned to either thermoneutral (TN; 20 degrees C, 20% RH) or HS (42 degrees C, 60% RH) chambers. The jugular vein of each heifer was cannulated and blood samples collected hourly for 4 h, then every 15 min for an additional 3 h. Oxytocin (100 IU) was injected (IV) 5 h after the start of blood collection. Plasma samples were assayed subsequently for concentrations of 13,14-dihydro-15-keto PGF2alpha (PGFM) and OT. During the 7-h experiment, body temperature of HS heifers reached 41.2 degrees C as compared to 38.5 degrees C in control heifers. Plasma concentrations of PGFM increased (P<0.05) and peaked 30 min after OT injection in C (890 pg/ml) and P (540 pg/ml) heifers. In C heifers, heat stress failed to alter PGFM concentrations either before or after OT injection. In the P group, PGFM concentrations following OT injection tended to be higher in HS heifers were further TN heifers (peak values of 690 vs. 410 pg/ml). Pregnant TN and HS heifers were further classified as responders or non-responders to OT challenge according to a cutoff value for PGFM of 193 pg/ml (overall mean of C heifers minus 1 SD). Five of six HS and one of five TN pregnant heifers were classified as responders (P<0.06). Oxytocin concentrations in plasma prior to injection of exogenous OT were not affected by HS or pregnancy status. It is concluded that in C heifers, acute HS in vivo does not cause any further rise in PGF2alpha secretion. However, in P heifers, HS appears to antagonize suppressive effects of the embryo on uterine secretion of PGF2alpha, as indicated by the larger proportion of P heifers responding to OT challenge.

Using scoping review methods to describe current capacity and prescribe change in Canadian SCI rehabilitation service delivery

OBJECTIVE

To describe the methodology used to conduct a scoping review of spinal cord injury (SCI) rehabilitation service delivery in Canada, and to explain the reporting process intended to advance future service delivery.

EVIDENCE ACQUISITION

A SCI rehabilitation framework derived from the International Classification of Function, Disability and Health was developed to describe the goals and interprofessional processes of rehabilitation. An adapted Arksey and O'Malley (2005) methodological framework was used to conduct a scoping review of SCI rehabilitation services in Canada. Data were obtained from multiple relevant sources via survey (N = 3572 data fields) from 13 of 15 Canadian tertiary SCI rehabilitation sites, systematic reviews, white papers, literature reviews, clinical practice resources, and clinicians. Multidisciplinary teams of content experts (N = 17), assisted with data interpretation and validation by articulating practice trends, gaps, and priorities.

EVIDENCE SYNTHESIS

The findings will be presented in an atlas, which includes aggregate national data regarding impairment and demographic characteristics, service utilization, available resources (staff and capital equipment), specialized services, local expertise, and current best practice indicators, outcome measures, and clinical guidelines. Data were collated and synthesized relative to specific rehabilitation goals. The current state of SCI rehabilitation service delivery (specific to each rehabilitation goal) is summarized in a report card within three domains, knowledge generation, clinical application, and policy change, and specifies key 2020 priorities.

CONCLUSION

These findings should prompt critical evaluation of current Canadian SCI rehabilitation service delivery while specifying enhancements in knowledge generation, clinical application and policy change domains likely to assist with achievement of best practices by 2020.

Herpes simplex virus vector-mediated delivery of glial cell line-derived neurotrophic factor rescues erectile dysfunction following cavernous nerve injury

Erectile dysfunction (ED) is frequently associated with injury to the cavernous nerve sustained during pelvic surgery. Functional recovery from cavernous nerve injury is generally incomplete and occurs over an extended time frame. We employed a therapeutic gene transfer approach with herpes simplex virus (HSV) vector expressing glial cell line-derived neurotrophic factor (GDNF). Rat cavernous nerve was injured bilaterally using a clamp and dry ice. For HSV-treated groups, 20 microl of purified vector stock was administered directly to and around the damaged nerve. Delivery of an HSV vector expressing both green fluorescent protein (GFP) and lacZ (HSV-LacZ) was used as a control. Intracavernous pressure along with systemic arterial pressure (ICP/AP) was measured 2 and 4 weeks after the nerve injury. Fluorogold (FG) was injected into the penile crus 7 days before killing to assess nerve survival. Approximately 60% of major pelvic ganglion (MPG) cells were GFP positive after viral administration. At 4 weeks after nerve injury, rats treated with HSV-GDNF exhibited significant recovery of ICP/AP compared with control vector or untreated groups. The HSV-GDNF group also yielded more FG-positive MPG cells than the control vector group. HSV vector-mediated delivery of GDNF presents a viable approach for the treatment of ED following cavernous nerve injury.

Prolonged preservation of nerve function in diabetic neuropathy in mice by herpes simplex virus-mediated gene transfer

AIMS/HYPOTHESIS

The aim of this study was to determine whether prolonged expression of neurotrophin-3 (NT-3) in mice, achieved by herpes simplex virus (HSV)-mediated gene transfer with gene expression under the control of an HSV latency promoter, can provide protection against the progression of diabetic neuropathy over a 6 month period.

MATERIALS AND METHODS

Mice with diabetes induced by streptozotocin were inoculated s.c. into both hind feet with a non-replicating HSV vector containing the coding sequence for NT-3 under the control of the HSV latency-associated promoter 2 (LAP2) elements or with a control vector. Nerve function was evaluated by electrophysiological and behavioural measures over the course of 6 months after the onset of diabetes.

RESULTS

Animals inoculated with the NT-3-expressing vector, but not animals inoculated with control vector, showed preservation of sensory and motor nerve amplitude and conduction velocity measured electrophysiologically, small fibre sensory function assessed by withdrawal from heat, autonomic function measured by pilocarpine-induced sweating, skin innervation assessed by protein gene product 9.5 staining of axons, and density of calcitonin gene-related peptide terminals in the spinal cord measured by immunohistochemistry 5.5 months after vector inoculation.

CONCLUSIONS/INTERPRETATION

These results indicate that the continuous production of NT-3 by LAP2-driven expression of the transgene from an HSV vector over a 6 month period protects against progression of diabetic neuropathy in mice, and provide a proof-of-principle demonstration for the development of a novel therapy for preventing the progression of diabetic neuropathy.

HSV-mediated gene transfer of vascular endothelial growth factor to dorsal root ganglia prevents diabetic neuropathy

We examined the utility of herpes simplex virus (HSV) vector-mediated gene transfer of vascular endothelial growth factor (VEGF) in a mouse model of diabetic neuropathy. A replication-incompetent HSV vector with VEGF under the control of the HSV ICP0 promoter (vector T0VEGF) was constructed. T0VEGF expressed and released VEGF from primary dorsal root ganglion (DRG) neurons in vitro, and following subcutaneous inoculation in the foot, expressed VEGF in DRG and nerve in vivo. At 2 weeks after induction of diabetes, subcutaneous inoculation of T0VEGF prevented the reduction in sensory nerve amplitude characteristic of diabetic neuropathy measured 4 weeks later, preserved autonomic function measured by pilocarpine-induced sweating, and prevented the loss of nerve fibers in the skin and reduction of neuropeptide calcitonin gene-related peptide and substance P in DRG neurons of the diabetic mice. HSV-mediated transfer of VEGF to DRG may prove useful in treatment of diabetic neuropathy.

Safety and biodistribution studies of an HSV multigene vector following intracranial delivery to non-human primates

Malignant glioma is a fatal human cancer in which surgery, chemo- and radiation therapies are ineffective. Therapeutic gene transfer used in combination with current treatment methods may augment their effectiveness with improved clinical outcome. We have shown that NUREL-C2, a replication-defective multigene HSV-based vector, is effective in treating animal models of glioma. Here, we report safety and biodistribution studies of NUREL-C2 using rhesus macaques as a model host. Increasing total doses (1 x 10(7) to 1 x 10(9) plaque forming units (PFU)) of NUREL-C2 were delivered into the cortex with concomitant delivery of ganciclovir (GCV). The animals were evaluated for changes in behavior, alterations in blood cell counts and chemistry. The results showed that animal behavior was generally unchanged, although the chronic intermediate dose animal became slightly ataxic on day 12 postinjection, a condition resolved by treatment with aspirin. The blood chemistries were unremarkable for all doses. At 4 days following vector injections, magnetic resonance imaging showed inflammatory changes at sites of vector injections concomitant with HSV-TK and TNFalpha expression. The inflammatory response was reduced at 14 days, resolving by 1 month postinjection, a time point when transgene expression also became undetectable. Immunohistochemical staining following animal killing showed the presence of a diffuse low-grade gliosis with infiltrating macrophages localized to the injection site, which also resolved by 1 month postinoculation. Viral antigens were not detected and injected animals did not develop HSV-neutralizing antibodies. Biodistribution studies revealed that vector genomes remained at the site of injection and were not detected in other tissues including contralateral brain. We concluded that intracranial delivery of 1 x 10(9) PFU NUREL-C2, the highest anticipated patient dose, was well tolerated and should be suitable for safety testing in humans.

HSV vector-mediated transduction and GDNF secretion from adipose cells

The accessibility of adipose tissue and its ability to secrete various bioactive molecules suggest that adipose cells may be attractive targets for gene therapy applications. Here, we report the use of highly defective herpes simplex virus (HSV) vectors as suitable gene transfer agents for adipose cells in culture and fat tissue in animals. Using an in vitro model of human adipose differentiation, we first demonstrated that mature adipocytes and their precursor cells express the two principal HSV viral entry receptors HveA and HveC (nectin-1) and are efficiently transduced at a low multiplicity of infection by HSV-lacZ reporter gene and glial cell line-derived neurotrophic factor (GDNF) gene vectors. Extended expression of beta-galactosidase and secretion of GDNF occurred in transduced fat tissue explants from rabbits. In vivo gene transfer to rabbit subcutaneous adipose tissue resulted in local GDNF expression for at least 2 months. These experiments establish the efficient transduction of adipose cells by HSV vectors and suggest that fat tissue may represent a useful site for HSV-mediated gene delivery with potential for therapeutic applications.

Measurement of analyzing power for proton-carbon elastic scattering in the coulomb-nuclear interference region with a 22-GeV/c polarized proton beam

The analyzing power for proton-carbon elastic scattering in the Coulomb-nuclear interference region of momentum transfer, 9.0x10(-3)<-t<4.1x10(-2) (GeV/c)(2), was measured with a 21.7 GeV/c polarized proton beam at the Alternating Gradient Synchrotron of Brookhaven National Laboratory. The ratio of hadronic spin-flip to nonflip amplitude, r(5), was obtained from the analyzing power to be Rer(5)=0.088+/-0.058 and Imr(5)=-0.161+/-0.226.

Multiple maltreatment, attribution of blame, and adjustment among adolescents

The study examined the predictive utility of blame attributions for maltreatment. Integrating theory and research on blame attribution, it was predicted that self-blame would mediate or moderate internalizing problems, whereas other-blame would mediate or moderate externalizing problems. Mediator and moderator models were tested separately. Adolescents (N = 160, ages 11-17 years) were randomly selected from the open caseload of a child protection agency. Participants made global maltreatment severity ratings for each of physical abuse, psychological abuse, neglect. sexual abuse, and exposure to family violence. Participants also completed the Attribution for Maltreatment Interview (AFMI), a structured clinical interview that assessed self- and perpetrator blame for each type of maltreatment they experienced. The AFMI yielded five subscales: self-blaming cognition, self-blaming affect, self-excusing. perpetrator blame, and perpetrator excusing. Caretaker-reported (Child Behavior Checklist) and self-reported (Youth Self Report) internalizing and externalizing were the adjustment criteria. Controlling for maltreatment severity, the AFMI subscales explained significant variance in self-reported adjustment. Self-blaming affect was the most potent attribution, particularly among females. Attributions mediated maltreatment severity for self-reported adjustment but moderated it for caretaker-reported adjustment. The sophistication and relevance of blame attributions to adjustment are discussed, and implications for research and clinical practice are identified.

Double suicide gene therapy using a replication defective herpes simplex virus vector reveals reciprocal interference in a malignant glioma model

Herpes simplex virus thymidine kinase (HSV-TK) and Escherichia coli cytosine deaminase (CD) are non-mammalian enzymes capable of converting innocuous prodrugs into cytotoxic metabolites. Both enzymes have been utilized independently, as well as together in 'suicide' gene therapy protocols to eliminate tumor cells in vitro and in vivo. We have used a set of replication defective HSV vectors expressing either or both enzymes to compare the efficacies of single and double suicide gene therapies in the 9L gliosarcoma model in vitro and in vivo. In cell culture experiments at high and low multiplicities of infection, combined expression of the two genes by vector TOCD/TK along with exposure to the matching prodrugs (ganciclovir and 5-fluorocytosine) showed increased cytotoxicity compared with exposure to either prodrug alone. However, the two gene combination was inferior to single gene treatments, suggesting that HSVtk and CD are mutually counteractive in the prodrug-dependent killing of glioma cells. In animal experiments, survival was not significantly prolonged by administration of both prodrugs to TOCD/TK-treated animals, while each single gene/prodrug pair resulted in increased survival. These results indicate that single suicide gene systems employing HSVtk or CD may be preferable over combinations of the two.