Towards precision medicine for anxiety disorders: objective assessment, risk prediction, pharmacogenomics, and repurposed drugs

Anxiety disorders are increasingly prevalent, affect people's ability to do things, and decrease quality of life. Due to lack of objective tests, they are underdiagnosed and sub-optimally treated, resulting in adverse life events and/or addictions. We endeavored to discover blood biomarkers for anxiety, using a four-step approach. First, we used a longitudinal within-subject design in individuals with psychiatric disorders to discover blood gene expression changes between self-reported low anxiety and high anxiety states. Second, we prioritized the list of candidate biomarkers with a Convergent Functional Genomics approach using other evidence in the field. Third, we validated our top biomarkers from discovery and prioritization in an independent cohort of psychiatric subjects with clinically severe anxiety. Fourth, we tested these candidate biomarkers for clinical utility, i.e. ability to predict anxiety severity state, and future clinical worsening (hospitalizations with anxiety as a contributory cause), in another independent cohort of psychiatric subjects. We showed increased accuracy of individual biomarkers with a personalized approach, by gender and diagnosis, particularly in women. The biomarkers with the best overall evidence were GAD1, NTRK3, ADRA2A, FZD10, GRK4, and SLC6A4. Finally, we identified which of our biomarkers are targets of existing drugs (such as a valproate, omega-3 fatty acids, fluoxetine, lithium, sertraline, benzodiazepines, and ketamine), and thus can be used to match patients to medications and measure response to treatment. We also used our biomarker gene expression signature to identify drugs that could be repurposed for treating anxiety, such as estradiol, pirenperone, loperamide, and disopyramide. Given the detrimental impact of untreated anxiety, the current lack of objective measures to guide treatment, and the addiction potential of existing benzodiazepines-based anxiety medications, there is a urgent need for more precise and personalized approaches like the one we developed.

Early disease course is unaltered in mucopolysaccharidosis type IIIA (MPS IIIA) mice lacking α-synuclein

BACKGROUND

Sanfilippo syndrome (mucopolysaccharidosis type IIIA; MPS IIIA) is an inherited paediatric-onset neurodegenerative disorder caused by the lysosomal deficiency of sulphamidase with subsequent accumulation of heparan sulphate. The pathological mechanisms responsible for clinical disease are unknown; however, intraneuronal accumulation of aggregation-prone proteins such as α-synuclein, phosphorylated tau and amyloid precursor protein suggests inefficient intracellular trafficking and lysosomal degradation.

AIM

To investigate the contribution the accumulating α-synuclein plays in early symptom emergence that is, impaired cognition, reduced anxiety and motor deficits, first detectable between 3-5 months of age.

METHODS

We have crossed congenic MPS IIIA mice with α-synuclein-deficient (Snca^tm1Rosl /J) mice and evaluated phenotype and brain disease lesions.

RESULTS

In a battery of behavioural tests performed on mice aged 12-22 weeks, we were unable to differentiate α-synuclein-deficient MPS IIIA mice from those with one or both copies of the α-synuclein gene; all three affected genotypes were significantly impaired in test performance when compared to wild-type littermates. Histological studies revealed that the rate, location and nature of deposition of other proteinaceous lesions, the disruption to endolysosomal protein expression and the inflammatory response seen in the brain of α-synuclein-deficient MPS IIIA mice reflected that seen in MPS IIIA mice homo- or heterozygous for α-synuclein.

CONCLUSION

Deletion and/or deficiency of α-synuclein does not influence clinical and neuropathological disease progression in murine MPS IIIA, demonstrating that in and of itself, this protein does not initiate the cognitive and motor symptoms that occur in the first 5 months of life in MPS IIIA mice.

Cluster-Randomized Trial of a Behavioral Intervention to Incorporate a Treat-to-Target Approach to Care of US Patients With Rheumatoid Arthritis

Objective

To assess the feasibility and efficacy of implementing a treat‐to‐target approach versus usual care in a US‐based cohort of rheumatoid arthritis patients.

Methods

In this behavioral intervention trial, rheumatology practices were cluster‐randomized to provide treat‐to‐target care or usual care. Eligible patients with moderate/high disease activity (Clinical Disease Activity Index [CDAI] score >10) were followed for 12 months. Both treat‐to‐target and usual care patients were seen every 3 months. Treat‐to‐target providers were to have monthly visits with treatment acceleration at a minimum of every 3 months in patients with CDAI score >10; additional visits and treatment acceleration were at the discretion of usual care providers and patients. Coprimary end points were feasibility, assessed by rate of treatment acceleration conditional on CDAI score >10, and achievement of low disease activity (LDA; CDAI score ≤10) by an intent‐to‐treat analysis.

Results

A total of 14 practice sites per study arm were included (246 patients receiving treat‐to‐target and 286 receiving usual care). The groups had similar baseline demographic and clinical characteristics. Rates of treatment acceleration (treat‐to‐target 47% versus usual care 50%; odds ratio [OR] 0.92 [95% confidence interval (95% CI) 0.64, 1.34]) and achievement of LDA (treat‐to‐target 57% versus usual care 55%; OR 1.05 [95% CI 0.60, 1.84]) were similar between groups. Treat‐to‐target providers reported patient reluctance and medication lag time as common barriers to treatment acceleration.

Conclusion

This study is the first to examine the feasibility and efficacy of a treat‐to‐target approach in typical US rheumatology practice. Treat‐to‐target care was not associated with increased likelihood of treatment acceleration or achievement of LDA, and barriers to treatment acceleration were identified.

Impacted urethral calculus discovered on pelvic ultrasound: a case report

Most urinary tract calculi are formed in the upper urinary tract while urethral calculi are uncommon. In young men, lower urinary tract symptoms are often due to infections and are treated with antibiotics, but unusual causes may be overlooked. We present a case of an impacted urethral calculus in an otherwise healthy young male who presented with several months of lower urinary tract symptoms.

Defining the current negative appendectomy rate: for whom is preoperative computed tomography making an impact?

BACKGROUND

Historically, the negative appendectomy rate (NAR) for patients operated on for acute appendicitis (AA) has exceeded 20%. We sought to define the current NAR with increased use of computed tomography (CT) and laparoscopy.

METHODS

Records of 1425 consecutive patients undergoing appendectomy for suspicion of AA during the past 7 years at a single institution were reviewed. The NAR was calculated and compared with earlier data from this institution (1995-1999). Statistical methods included the Fisher exact test and the Student t test; differences of P < .05 were considered statistically significant.

RESULTS

The overall NAR was 7.65% compared to 16.3% over the period 1995-1999 (P = .0001), without a change in the perforation rate. Concurrently, the rate of preoperative CT increased from 32% to 95%. CT was associated with a lesser NAR only among adult females (7.6% vs 20.8%, P = .005) but not among adult males or children. No difference in NAR was noted in comparing laparoscopic and open appendectomy. Patients without AA had a greater mean duration of symptoms and lower white blood cell count at presentation than those with AA. Most patients undergoing negative appendectomy had a CT, and more than 50% had CT interpretations that were positive for, or could not exclude, AA.

CONCLUSIONS

The NAR in our hospital has decreased progressively to approximately 5%. Although preoperative CT is used in almost all patients, it is only associated with a lesser NAR among adult females. False-positive CTs may contribute to the residual NAR, and further data are needed to determine whether subgroups of male or pediatric patients benefit from preoperative CT.

The use of personal protective measures in control of malaria in a defined community

Malaria is one of the main health problems in the non-immune immigrant workers and army personnel of the malaria endemic areas in Myanmar. Due to changes in the vector bionomics and multiresistant strains of P. falciparum, chemoprophylaxis alone is not an effective means of control of malaria in them. So it is envisaged that the combined used of personal protective measures (deltamethrin impregnated bed-nets, scalves and hand-bands) and the chemoprophylaxis will be an effective means of control of malaria in the define group of people. The study also intended to find out the side effects of the deltamethrin and feasibility and acceptability of methods by the users. The study was conducted in Theini Township, Northern Shan State, from March to November 1993. The study population consisted of all ages of both sexes 554 and 440 persons in the test and control groups respectively. At the initial phase of the study, malaria infected persons from both the groups were treated. The experimental group received personal protective measures with impregnation of bed-nets using 25 mg ai/m2 of deltamethrin at 4 monthly intervals and the scarves and hand-bands at twice the concentration of the insecticides at monthly intervals. Chemoprophylaxis was given to both the groups at weekly intervals using age adjusted dosage of Pyrixine tablet (sulfadoxine-pyrimethamine). The parasitological, entomological, and epidemiological indices were collected at two month intervals in both the groups. The study clearly showed the impact of personal protective measures and chemoprophylaxis on malaria infection in the studied subjects. During the study period, the out patient malaria cases of the test group was 6% to 11.2% and that of the control group was 12% to 21.6% in Theini Hospital. The reinfection rate of the test group (0.9 to 4.7%) was also significantly lower than the control group (6.1 to 14.3%) from July to November. Acceptance of the treated bed-nets, scarves and hand-bands was high and good compliance was found in the follow up. The results of the study clearly showed that malaria can be controlled effectively in the defined group of persons for a malaria transmission season by using chemoprophylaxis and personal protective measures.